Rheumatic heart disease (RHD) is a medical condition that occurs after a patient develops rheumatic fever. Sadly, RHD often damages the heart valves of its victims permanently. Although this deadly disease mainly affects children aged 5 to 15 years, it can affect people of all ages. That said, here is everything you need to know about rheumatic heart disease:
An Overview of Rheumatic Fever
Before proceeding further, it is necessary to look at the precursor to RHD. Rheumatic fever is an inflammatory disease caused by group A Streptococcus bacteria (responsible for causing strep throat infections) and it precedes development of rheumatic heart disease. RF can affect numerous body tissues including the heart, joints, skin and brain tissue. Nevertheless, strep throat infections do not necessarily lead to rheumatic fever. In addition, unlike strep throat infections, RF is not contagious. In fact, the bacteria responsible for strep throat infection can be spread via direct contact with respiratory or oral secretions.
Children who exhibit symptoms such as fever, pain when swallowing, abdominal pain, vomiting, nausea, sudden sore throat onset, and headache are likely to be suffering from strep throat infection. It is worth noting that the group A beta-haemolytic Streptococcus bacteria can damage almost every part of the heart including the outer sac (pericardium), inner lining (endocardium), as well as the valves. Nevertheless, damage to the heart valves does not typically occur immediately. As such, several years could pass before a child who fell sick with rheumatic fever develops heart valve damage or exhibits symptoms associated with RHD.
How the RF Bacteria Works
The group A hemolytic Streptococcus bacteria attaches to the upper respiratory tract and proceeds to produce enzymes that eventually invade and damage diverse body tissues. Within 2 to 4 days of contracting this bacteria strain, the patient may develop symptoms such as headache, sore throat, fever, elevated leukocyte count, and malaise. These symptoms are physical manifestations of an acute inflammatory response to the streptococcus bacteria.
Rheumatic fever symptoms vary and can occur anywhere from one to five weeks after picking up group A Streptococcus bacteria. The common symptoms include:
• Change in neuromuscular movements. According to the Children’s Hospital of Wisconsin, changes in a child’s writing or jerky movements are good indicators of neuromuscular motion disturbances.
• Joint inflammation that may be accompanied by redness, tenderness, and swelling of the affected joints. In most cases, this type of inflammation affects large joints such as those in the knees or ankles.
• Pinkish rash that usually develops on the arms, legs, or trunk of the body.
• Stomach pain
• Small, hard nodules that develop under the surface of the skin
• Weight loss
• Shortness of breath
• Nose bleeding
If your child has developed some or all of the symptoms listed above, you should consult a qualified physician immediately. In the US, most doctors use the modified Jones criteria to diagnose RF. More specifically, physicians identify two major or one major and two minor criteria to confirm rheumatic fever diagnosis. The major diagnostic criteria include presence of subcutaneous nodules, carditis, erythema marginatum, chorea and polyarthritis. On the other hand, minor diagnostic criteria include leukocytosis, fever and arthralgia.
Unfortunately, there is no cure for rheumatic fever itself. As such, doctors generally prescribe treatment regimens that focus on clearing the streptococcal infection, thereby preventing its progression to RHD. Luckily, antibiotics can clear strep throat infections and prevent it from developing into rheumatic fever.
An Overview of RHD
Rheumatic heart disease refers to the permanent damage of the heart valves after a single or multiple bouts of rheumatic fever. This condition can affect the mitral valve (65-70% of patients), aortic valve (about 25% of patients), or both. Damage to these heart valves may cause:
• Inflammation and weakening of heart muscles leading to poor pumping function.
• Narrowing of the affected heart valve, which leads to decreased blood flow. Physicians call this condition valve stenosis.
• Blood flow in the wrong direction due to the leaking of blood in the affected valve. Medical experts call such a condition valve regurgitation.
• Heart failure due to the inability of the heart to pump enough blood throughout the body.
• Irregular heartbeats or atrial fibrillation especially in the upper chambers of the heart.
According to data from the University of Pittsburgh, about 40 to 60% of rheumatic fever patients eventually develop RHD. Moreover, an article published by the Seattle Children’s states that rheumatic heart disease symptoms show up to 20 years after the initial rheumatic fever bout.
Some of the common rheumatic heart disease symptoms include:
• Shortness of breath
• Heart palpitations/heart fluttering
• Swollen ankles and wrists
• Thumping sensation in the chest
• Chest pain
At this point, it is worth noting that your child may exhibit the rheumatic fever symptoms discussed earlier as well.
The leading risk factor is age, with most RHD patients aged 5 to 15 years. In addition, children born in families with a history of rheumatic heart disease are more likely to develop the same condition compared to children from families without similar medical history. Another risk factor is frequent strep throat infections especially in children who have received inadequate medical attention after past RF episodes. According to the University of Pittsburgh, rheumatic fever can only be caused by streptococcal infection of the pharynx and it recurs after re-infection of the same region. Finally, this condition is more prevalent in developing countries than in developed nations. For instance, the Children’s Hospital in Wisconsin states that very few children in the US develop RHD largely due to better health care and widespread awareness of the disease.
To start with, a doctor will review the medical history of a patient to overrule other medical conditions. Then, the doctor will perform a physical exam and find out how the patient feels. If the diagnosis is inconclusive, blood and heart activity tests may be necessary. These include echocardiogram, electrocardiogram, throat culture, rapid antigen detection test, antibody test, and chest roentgenography. Doctors usually require patients to return severally for further antigen tests. In some cases, heart catheterization may be necessary especially when a doctor suspects a patient has acute rheumatic heart disease.
Since RHD is a disease that hinges on an underlying condition, its treatment requires a multi-pronged approach. To start with, doctors prescribe medication to eliminate the streptococcal bacteria (if any are present). Patients are also given steroidal or non-steroidal medication to suppress inflammation of the heart and other parts of the body. Thirdly, most patients require diuretics (water pills) to prevent congestive heart failure and anticonvulsant medications as well. These steps represent the first phase of a long term orlifelong treatment strategy. The next treatment phase focuses on preventing the progression of RHD as well as monitoring symptoms and potential complications over time. In fact, this treatment phase continues until adulthood if the patient is a child.
For patients with group A beta hemolytic streptococci (GABHS), doctors prescribe oral penicillin. Amoxicillin or ampicillin are also effective in clearing GABHS. After completing the initial course of antibiotics, doctors prescribe continuous antibiotic therapy for up to 20 years or for life. If a patient is allergic to penicillin, the rule of thumb is to prescribe erythromycin or a cephalosporin-class drug. It is important to note that children with GABHS may be required to stay at home (not attend school) for the first 24 hours after starting antibiotic therapy. Adults with the same condition should avoid interacting with others over a similar timeline. Patients diagnosed with recurrent group A streptococci (GAS) pharyngitis are usually given a 10-day antibiotic course. If a patient does not show signs of improvement 24-36 hours after starting treatment, it is advisable to revisit the initial diagnosis.
For patients with severely damaged heart valves, doctors typically perform surgery to repair or replace the affected valves with artificial ones. For instance, if a doctor detects leakage severe enough to strain and enlarge the heart, he/she will recommend surgery to plug the leak. Where the affected valve has narrowed down, surgeons perform a surgical procedure called balloon valvuloplasty (inserting and inflating a special balloon to widen narrow valves).
RHD patients require regular exams and blood tests to check the condition of their heart. Moreover, your doctor may recommend bed rest for several weeks or months depending on the degree of inflammation associated with rheumatic fever.
Impact of Rheumatic Heart Disease
Many RHD patients in developing countries are unable to access proper healthcare due to financial constraints. Data from the World Heart Federation shows that up to 1% of children in Latin America, Africa, Asia, and the East Mediterranean region have RHD. Out of these, 233,000 die annually from RHD complications. Currently, the WHF reckons that there are 15.6 million people with RHD worldwide and a significant percentage require frequent hospitalization. Many of these also need heart surgery within the next five to 20 years. The only problem is most of these patients live in developing countries and may not be able to pay for surgery.
Rheumatic heart disease is a medical condition caused by the group A Streptococcus bacteria and mostly affects children aged 5 to 15 years. The disease typically damages vital parts of the heart such as the mitral and aortic valves and as such, RHD patients are often prone to heart attack, premature death due to heart failure and breathing difficulties.