INTRODUCTIO

The commonest valves

affecting are the mitral
and aortic, in that order.
However all four valves
can be affected.
Rheumatic heart
disease is a chronic
condition resulting from
rheumatic fever which
involves all the layers of
the heart (i.e.
pancarditis) and is
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characterized by
scarring and deformity
of the heartvalves.
RHEUMATIC HEART
DISEASE

• It is thought that 40-60% of patients with

ARF will go on to developing RHD.•
Rheumatic fever is a diffuse inflammatory
disease characterized by a delayed
response to an infection by group A beta-
hemolytic streptococci (GAS) in the
tonsilopharyngeal area, affecting the
heart, joints, central nervous system, skin
and subcutaneous tissues.
 Rheumatic Heart
Disease
• The disease is seen more
commonly in poor socio-economic
strata of the society living in damp
and overcrowded places.
• Rheumatic fever occurs in equal
numbers in males and females,
but the prognosis is worse for
females than for males.
• Rheumatic fever is principally a
disease of childhood, with a
median age of 10 years, although
it also occurs in adults (20% of
cases).
INCIDENCE
INCIDENCE
⮚ The incidence of rheumatic fever
(RF) varies from 0.2 to 0.75/1000/
year in school children 5–15 years
of age (2001 Govt.
ETIOLOGY
✔ Rheumatic fever• Group A beta-
hemolytic streptococcus.
 ✔ Age: It appears most commonly in children between the age of 5 to 15

RHEUMATIC
years.•
✔ Over-crowding: People who are living in a slum or damp area are

HEART more prone to get Rheumatic heart disease. •

✔ Poor socio-economic status: People who are poor and belong to low
DISEASE socio-economic conditions are prone to get Rheumatic heart disease.
✔ Upper respiratory tract infection: Rheumatic fever is an outcome of
RISK FACTORS upper respiratory tract infection with group A beta- hemolytic
streptococcus.
✔ Climate and season: It occurs more in the rainy season and in the cold
climate.
✔ Genetic predisposition: Rheumatic heart disease shows familiar
tendency.
✔ Previous history of Rheumatic fever: The clients with previous history
of Rheumatic fever are at high risk to develop Rheumatic heart disease.
RHEUMATIC HEART DISEASE
PATHOPHYSIOLOGY Causative agent
(Group A Beta-hemolytic streptococci)
 Untreated Strep throat Rheumatic fever
✔ All layers of the heart and the mitral valve become inflamed
Vegetation forms Valvular regurgitations and stenosis Heart failure

CLINICAL MANIFESTATIONS
 ● Subcutaneous nodules
 ● Erythema marginatum
 ● Chorea
 ● Polyarthritis
 ● Carditis
CLINICAL MANIFESTATIONS Major
manifestations ( RHD)
• 1. Carditis
• 2. Arthritis
• 3. Chorea
• 4. Erythema marginatum
• 5. Subcutaneous nodules
RHD-Minor
manifestations
include:
• 1. Arthralgia
• 2. Fever associated with
weakness,
• 3. malaise,
• 4. weight loss and
• 5. anorexia
Laboratory findings
in RHD
1. Positive throat culture for group A beta- hemolytic
streptococci
2. Elevated acute phase reactants:
a) Erythrocyte sedimentation rate
b) C-reactive protein
c) Leukocytosis
3. Prolonged P-R interval
 1. The modified Jones criteria (revised in 1992) provide
DIAGNOSTI guidelines for the diagnosis of rheumatic fever.• A diagnosis
of rheumatic heart disease is made after confirming
C antecedent rheumatic fever.

EVALUATIO • 2. 1 major and 2 minor⎫ 2 major or ⎫JONES CRITERIA

✔ Subcutaneous nodules• Erythema marginatum • Chorea •
N Polyarthritis • Carditis •Major manifestations ¬
Jones’ criteria for the diagnosis of Rheumatic fever
✔ Fever associated with weakness, malaise, weight loss and
anorexia• Arthralgia • Previous rheumatic fever or rheumatic
heart disease.
Clinical findings
1. Chest X-ray shows enlarged
heart.
2. ECG and echocardiogram to
confirm rhythm problems and
structural changes (prolonged P-
R interval).
3. Elevated ESR, C-reactive
protein and Leukocytosis
 Laboratory findings
1. Recent scarlet fever
2. Elevated or rising anti-streptococcal antibody titer
3. Positive throat culture for strep A
4. Evidence of Group A streptococcal infection
5. Cardiomegaly, pulmonary congestion,¬ Chest
roentgenography : •IMAGING STUDIES and other findings
consistent with heart failure may be seen on chest
radiography.
6. In acute rheumatic heart disease, Doppler-
echocardiography identifies and quantities valve
insufficiency and ventricular dysfunction.¬ Doppler-
echocardiogram •
⮚ In chronic rheumatic heart disease, echocardiography
may be used to track the progression of valve stenosis and
may help determine the time for surgical intervention.
⮚ With chronic disease, heart catheterization has been
performed to evaluate mitral and aortic valve disease and
to balloon stenotic mitral valves.
⮚ In acute rheumatic heart disease, this procedure is not
indicated.
ON ECG

✔ Patients with rheumatic heart disease also may develop atrial flutter, multifocal atrial
tachycardia, or atrial fibrillation from chronic mitral valve disease and atrial dilation.

✔ Sinus tachycardia most frequently accompanies acute rheumatic heart disease.

Alternatively, some children develop sinus bradycardia from increased vagal tone.

✔ Aschoff bodies (perivascular foci of eosinophilic collagen surrounded by lymphocytes,

plasma cells, and macrophages) are found in the pericardium, perivascular regions of the
myocardium, and endocardium.• Pathologic examination of the insufficient valves may reveal
verrucous lesions at the line of closure.
HISTOLOGIC FINDINGS
✔ In the pericardium, fibrinous
and serofibrinous exudates
may produce an appearance of
"bread and butter";
pericarditis.
✔ Anitschkow cells are plump ✔ An injection of 0.6-1.2 ✔ Primary prophylaxis (initial ✔ Preventive and prophylactic
macrophages within Aschoff million units of benzathine course of antibiotics therapy is indicated after
bodies penicillin G intramuscularly administered to eradicate the rheumatic fever and acute
every 4 weeks is the streptococcal infection) also rheumatic heart disease to
recommended regimen for serves as the first course of prevent further damage to
secondary prophylaxis for most secondary prophylaxis valves.
US patients. (prevention of recurrent
rheumatic fever and rheumatic
heart disease).
MEDICAL MANAGEMENT

Eradicate infection

Patients with rheumatic fever with carditis and valve disease should receive
antibiotics for at least 10 years or until age 40 years.

Continue antibiotic prophylaxis indefinitely for patients at high risk (eg, health
care workers, teachers, daycare workers) for recurrent GABHS infection.

Administer the same dosage every 3 weeks in areas where rheumatic fever is
endemic, in patients with residual carditis, and in high-risk patients.
MEDICAL MANAGEMENT
✔Do not use penicillin, ampicillin, or amoxicillin for endocarditis prophylaxis in patients already receiving penicillin
for secondary rheumatic fever prophylaxis (relative resistance of PO streptococci to penicillin and aminopenicillins ✔
Patients who had rheumatic fever without valve damage do not need endocarditis prophylaxis.

✔ Patients with rheumatic heart disease and valve damage require a single dose of antibiotics 1 hour before surgical
and dental procedures to help prevent bacterial endocarditis.

✔ Alternative drugs recommended by the American Heart Association for these patients include PO clindamycin (20
mg/kg in children, 600 mg in adults) and PO azithromycin or clarithromycin (15 mg/kg in children, 500 mg in adults).

✔ Corticosteroids are used to treat carditis, especially if heart failure

MEDICAL
MANAGEMENT
✔ Maximize cardiac output If heart
failure develops, treatment, including
ACE inhibitors, beta blockers and
diuretics, is effective and is evident.
✔ Bed rest is usually prescribed to
reduce cardiac effort until evidence of
inflammation has subsided.
✔ Clients with arthritic manifestations
obtain relief with salicylates.
✔ Promote comfort
 SURGICAL
MANAGEMENT
✔ Commissurotomy can be done to widen the valve.
✔ Forty percent of patients with acute rheumatic heart
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disease subsequently develop mitral stenosis as adults.
✔ When heart failure persists or worsens after
aggressive medical therapy for acute rheumatic heart
disease, surgery to decrease valve insufficiency may be
life-saving.
✔ Due to high rates of recurrent symptoms after
annuloplasty or other repair procedures, valve
replacement appears to be the preferred surgical
option
✔ In patients with critical stenosis, mitral valvulotomy,
percutaneous balloon valvuloplasty, or mitral valve
replacement may be indicated.

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 OBJECTIVES: The client verbalizes
increased comfort as evidenced by reports
of reduced discomfort, expression of joint
pain reduction, relaxed body posture and
a calm facial expression.
NURSING DIAGNOSIS: Pain related to
inflammatory response in the joints.
INTERVENTION:
•Administer analgesics as needed.
• Provide diversional therapy and
psychological support.
• Complete bed rest and provide a
NURSING comfortable position.
• Assess the level of pain, duration,
MANAGEMENT intensity and frequency of pain.
 • OBJECTIVES: client increases cardiac output as evidenced
by regular cardiac rhythm, heart rate, blood pressure,
respiration and urine output within normal limit.
• • NURSING DIAGNOSIS: Decreased cardiac output related
to valve dysfunction or HF.
INTERVENTIONS:
• Administration of cardiac glycosides as prescribed.
NURSING MANAGEMEN
T • Provide bed rest.
• Monitor intake and output.
• Assess for heart sounds.
• Assess the symptoms of heart failure and decreased
cardiac output including diminished quality of peripheral
pulses, cool skin and extremities, increased respiration,
increased heart rate, neck vein distention and presence of
edema.
 OBJECTIVES: clients shows
maximum reduction of anxiety
NURSING DIAGNOSIS: Anxiety
related to disease condition and
heart failure
INTERVENTIONS:
• Provide anxiolytics as
prescribed.
• Explain about the disease
conditions and prophylactic
treatment.
• Explain all activities,
procedures and issues that
involve the client.
• Clarify the doubts of the clients
by using non-medical terms and
calm, slow speech.
• Assess the client's level of
NURSING MANAGEMENT anxiety.