Rheumatic Carditis - Clinicals, Diagnosis, and Management

Cardiovascular

Clinicals - History

Fact Explanation
Chest pain, chest tightness Rheumatic fever (RF) is an autoimmune disease. Repeated RF episodes may cause rheumatic heart disease (RHD) due to progressive and permanent valvular
lesions
Chest pain occurs due to pancarditis and valvular heart lesions
Chest pain, chest tightness
Rheumatic fever (RF) is an autoimmune disease. Repeated RF episodes may cause rheumatic heart disease (RHD) due to progressive and permanent valvular
lesions
Chest pain occurs due to pancarditis and valvular heart lesions
Shortness of breath As a symptom of heart failure in severe rheumatic carditis Shortness of breath
As a symptom of heart failure in severe rheumatic carditis
Swelling of the ankles As a symptom of heart failure in severe rheumatic carditis Swelling of the ankles
As a symptom of heart failure in severe rheumatic carditis
Recent history of sore throat Rheumatic fever can occur after infections of oropharynx by the group A beta-hemolytic Streptococcus Recent history of sore throat
Rheumatic fever can occur after infections of oropharynx by the group A beta-hemolytic Streptococcus
Age between 5-15 years Rheumatic fever is more common in this age group Age between 5-15 years
Rheumatic fever is more common in this age group
Fever Minor criteria for the diagnosis of rheumatic fever Fever
Minor criteria for the diagnosis of rheumatic fever
Joint pain Non cardiac manifestations of rheumatic fever may be present.Migrating arthritis is a major criteria and arthralgia is a minor criteria for the diagnosis of rheumatic fever Joint pain
Non cardiac manifestations of rheumatic fever may be present.Migrating arthritis is a major criteria and arthralgia is a minor criteria for the diagnosis of rheumatic fever
Emotional lability, uncoordinated movements and muscle weakness Occurs in Sydenham’s chorea,which is a major criteria for the diagnosis of rheumatic fever Emotional lability, uncoordinated movements and muscle weakness
Occurs in Sydenham’s chorea,which is a major criteria for the diagnosis of rheumatic fever
Subcutaneous lumps Non cardiac manifestations of rheumatic fever may be present.Subcutaneous nodules are a minor criteria for the diagnosis of rheumatic fever Subcutaneous lumps
Non cardiac manifestations of rheumatic fever may be present.Subcutaneous nodules are a minor criteria for the diagnosis of rheumatic fever
Skin lesions Due to erythema marginatum (non cardiac manifestations of rheumatic fever) which is a minor criteria for the diagnosis of rheumatic fever Skin lesions
Due to erythema marginatum (non cardiac manifestations of rheumatic fever) which is a minor criteria for the diagnosis of rheumatic fever
Past history of rheumatic fever or rheumatic heart disease Minor criteria for the diagnosis of rheumatic fever Past history of rheumatic fever or rheumatic heart disease
Minor criteria for the diagnosis of rheumatic fever
Recent history of scarlet fever Rheumatic fever can occur after infections of oropharynx by the group A beta-hemolytic Streptococcus Recent history of scarlet fever
Rheumatic fever can occur after infections of oropharynx by the group A beta-hemolytic Streptococcus
overcrowding and unemployment Studies have shown that there is a trend towards increased risk of rheumatic heart disease in association with overcrowding and unemployment due to poor living conditions overcrowding and unemployment
Studies have shown that there is a trend towards increased risk of rheumatic heart disease in association with overcrowding and unemployment due to poor living conditions

Clinicals - Examination

Fact Explanation
Tachycardia / Increased rate of sleeping pulse Monitor the sleeping pulse.Tachycardia may occur as a result of cardiac arrhythmia or as a result of acute decompensation of heart in cardiac failure Tachycardia / Increased rate of sleeping pulse
Monitor the sleeping pulse.Tachycardia may occur as a result of cardiac arrhythmia or as a result of acute decompensation of heart in cardiac failure
Audible friction rub Due to pericarditis.Can be supported by echocardiographic evidence of pericardial effusion Audible friction rub
Due to pericarditis.Can be supported by echocardiographic evidence of pericardial effusion
Shifted apex beat Due to cardiomegaly (myocarditis) Shifted apex beat
Due to cardiomegaly (myocarditis)
Heart murmurs Presence of apical holosystolic murmur of mitral regurgitation
(with or without apical mid-diastolic murmur, Carey Coombs), or basal early diastolic murmur in patients who do not have a history of rheumatic heart disease.On the other hand, in an individual with previous rheumatic heart disease, a definite change in the character of any of these murmurs or the appearance of a new significant murmur
indicates the presence of carditis
Heart murmurs
Presence of apical holosystolic murmur of mitral regurgitation
(with or without apical mid-diastolic murmur, Carey Coombs), or basal early diastolic murmur in patients who do not have a history of rheumatic heart disease.On the other hand, in an individual with previous rheumatic heart disease, a definite change in the character of any of these murmurs or the appearance of a new significant murmur
indicates the presence of carditis
Red,swollen,warm joints (Arthritis) Arthritis is the most frequent major manifestation of RF, occurring in up to 75% of patients in the first attack of RF.Typically present as migratory polyarthritis, more often in larger joints (ankles and knees commonly) Red,swollen,warm joints (Arthritis)
Arthritis is the most frequent major manifestation of RF, occurring in up to 75% of patients in the first attack of RF.Typically present as migratory polyarthritis, more often in larger joints (ankles and knees commonly)
Sydenham’s chorea Characterized by emotional lability, uncoordinated movements and muscle weakness Sydenham’s chorea
Characterized by emotional lability, uncoordinated movements and muscle weakness
Subcutaneous nodules The subcutaneous
nodules are round, firm, freely movable, painless lesions varying in
size from 0.5–2.0cm
Subcutaneous nodules
The subcutaneous
nodules are round, firm, freely movable, painless lesions varying in
size from 0.5–2.0cm
Erythema marginatum appear first as a bright pink
macule or papule that spreads outward in a circular or seripiginous
pattern. The lesions are multiple, appearing on the trunk or proximal extremities, rarely on the distal extremities, and never on the face
Erythema marginatum
appear first as a bright pink
macule or papule that spreads outward in a circular or seripiginous
pattern. The lesions are multiple, appearing on the trunk or proximal extremities, rarely on the distal extremities, and never on the face
Ankle edema, ascites Occur due to heart failure in severe rheumatic heart disease Ankle edema, ascites
Occur due to heart failure in severe rheumatic heart disease
Inflamed throat Recent history of streptococcal infection Inflamed throat
Recent history of streptococcal infection

Investigations - Diagnosis

Fact Explanation
Echocardiography Provides information about the size of atria and ventricles, valvular thickening,leaflet prolapse and ventricular dysfunction.The severity of valvular regurgitation has been classified based on the echocardiographic findings Echocardiography
Provides information about the size of atria and ventricles, valvular thickening,leaflet prolapse and ventricular dysfunction.The severity of valvular regurgitation has been classified based on the echocardiographic findings
Endomyocardial biopsy Since myocarditis is an obligatory component of cardiac involvement
in RF, the value of endomyocardial biopsy has been investigated
for diagnosing rheumatic carditis
Endomyocardial biopsy
Since myocarditis is an obligatory component of cardiac involvement
in RF, the value of endomyocardial biopsy has been investigated
for diagnosing rheumatic carditis
Radionuclide imaging Radiolabelled anti myosin antibodies and radiolabeled leukocytes are used to image myocardial inflammation Radionuclide imaging
Radiolabelled anti myosin antibodies and radiolabeled leukocytes are used to image myocardial inflammation
Chest x ray Detection of cardiomegaly, effusions Chest x ray
Detection of cardiomegaly, effusions
Electrocardiogram To detect arrhythmias and prolonged PR interval (minor criteria for the diagnosis of rheumatic fever) Electrocardiogram
To detect arrhythmias and prolonged PR interval (minor criteria for the diagnosis of rheumatic fever)
Antistreptolysin-O test Diagnosis of rheumatic fever requires prior streptococcal infection.
Although a single elevated titre is useful, it is recommended to perform another test 3-4 weeks after the onset of rheumatic fever
Antistreptolysin-O test
Diagnosis of rheumatic fever requires prior streptococcal infection.
Although a single elevated titre is useful, it is recommended to perform another test 3-4 weeks after the onset of rheumatic fever
Throat swab culture Positive throat culture for Group A beta-hemolytic streptococci gives an evidence of prior streptococcal infection. Throat swab culture
Positive throat culture for Group A beta-hemolytic streptococci gives an evidence of prior streptococcal infection.
Positive rapid direct Group A strep carbohydrate antigen test Gives an evidence of prior streptococcal infection. Positive rapid direct Group A strep carbohydrate antigen test
Gives an evidence of prior streptococcal infection.
Erythrocyte sedimentation rate/ C reactive proteins Acute phase reactants: Leukocytosis, elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) is a minor criteria for the diagnosis of rheumatic fever Erythrocyte sedimentation rate/ C reactive proteins
Acute phase reactants: Leukocytosis, elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) is a minor criteria for the diagnosis of rheumatic fever

Investigations - Management

Fact Explanation
Echocardiography Regular assessments with echocardiography are mandatory to confirm and monitor cardiac involvement
It is important to detect progression to severe chronic mitral or aortic lesions.
Also important to detect infective endocarditis which may occur secondary to rheumatic heart disease
Echocardiography
Regular assessments with echocardiography are mandatory to confirm and monitor cardiac involvement
It is important to detect progression to severe chronic mitral or aortic lesions.
Also important to detect infective endocarditis which may occur secondary to rheumatic heart disease
Acute phase reactants Check for the reduction of acute phase reactants Acute phase reactants
Check for the reduction of acute phase reactants
Erythrocyte sedimentation rate/ C reactive proteins High counts indicate a severe disease Erythrocyte sedimentation rate/ C reactive proteins
High counts indicate a severe disease
Full blood count Detection of high white blood cell counts due to streptococcal infection Full blood count
Detection of high white blood cell counts due to streptococcal infection
Antistreptolysin-O test To detect prior streptococcal infection
Although a single elevated titre is useful, it is recommended to perform another test 3-4 weeks after the onset of rheumatic fever
Antistreptolysin-O test
To detect prior streptococcal infection
Although a single elevated titre is useful, it is recommended to perform another test 3-4 weeks after the onset of rheumatic fever
Throat swab culture Positive throat culture for Group A beta-hemolytic streptococci gives an evidence of prior streptococcal infection. Throat swab culture
Positive throat culture for Group A beta-hemolytic streptococci gives an evidence of prior streptococcal infection.
Positive rapid direct Group A strep carbohydrate antigen test Gives an evidence of prior streptococcal infection. Positive rapid direct Group A strep carbohydrate antigen test
Gives an evidence of prior streptococcal infection.
Echocardiography Done to screen for the detection of rheumatic heart disease.The severity of valvular regurgitation has been classified based on the echocardiographic findings Echocardiography
Done to screen for the detection of rheumatic heart disease.The severity of valvular regurgitation has been classified based on the echocardiographic findings
Electrocardiogram To detect arrythmias and prolong PR interval Electrocardiogram
To detect arrythmias and prolong PR interval

Management - Supportive

Fact Explanation
Aspirin, 100 mg/kg-day divided into 4–5 doses Suppression of the inflammatory process.After achieving the desired initial steady-state concentration for two weeks, the dosage can be decreased to 60–70mg/kg-day for an additional 3–6 weeks Aspirin, 100 mg/kg-day divided into 4–5 doses
Suppression of the inflammatory process.After achieving the desired initial steady-state concentration for two weeks, the dosage can be decreased to 60–70mg/kg-day for an additional 3–6 weeks
Steroids Suppression of the inflammatory process.Patients with pericarditis or heart failure respond favorably to
corticosteroids; corticosteroids are also advisable in patients who do not respond to salicylates and who continue to worsen and develop heart failure despite anti-inflammatory therapy.Prednisone (1–
2 mg/kg-day, to a maximum of 80mg/day given once daily, or in
divided doses) is usually the drug of choice
Steroids
Suppression of the inflammatory process.Patients with pericarditis or heart failure respond favorably to
corticosteroids; corticosteroids are also advisable in patients who do not respond to salicylates and who continue to worsen and develop heart failure despite anti-inflammatory therapy.Prednisone (1–
2 mg/kg-day, to a maximum of 80mg/day given once daily, or in
divided doses) is usually the drug of choice
Treatment of heart failure Generally responds to bed rest and steroids.But in severe symptoms diuretics,angiotensin converting enzyme inhibitors and digoxin may be used Treatment of heart failure
Generally responds to bed rest and steroids.But in severe symptoms diuretics,angiotensin converting enzyme inhibitors and digoxin may be used
Management of chorea Haloperidol, diazepam are effective drugs Management of chorea
Haloperidol, diazepam are effective drugs
Analgesics For management of pain in arthritis.Usually paracetamol or non steroidal anti inflammatory drugs are used Analgesics
For management of pain in arthritis.Usually paracetamol or non steroidal anti inflammatory drugs are used
Control of fever Paracetamol is usually used Control of fever
Paracetamol is usually used
Antibiotics Single-dose IM benzathine benzylpenicillin (preferable) or 10 days oral penicillin ( oral erythromycin is given if allergic to penicillin) Antibiotics
Single-dose IM benzathine benzylpenicillin (preferable) or 10 days oral penicillin ( oral erythromycin is given if allergic to penicillin)
Primordial prevention Broad social, economic and environmental initiatives undertaken to prevent or limit the impact of Group A Streptococcal (GAS) infection in a population Primordial prevention
Broad social, economic and environmental initiatives undertaken to prevent or limit the impact of Group A Streptococcal (GAS) infection in a population
Primary prevention Reducing GAS transmission, acquisition, colonisation and carriage or treating GAS infection effectively to prevent the development of acute rheumatic fever in individuals Primary prevention
Reducing GAS transmission, acquisition, colonisation and carriage or treating GAS infection effectively to prevent the development of acute rheumatic fever in individuals
Secondary prevention Administering regular prophylactic antibiotics to individuals who have had an episode of acute rheumatic fever to prevent the development of rheumatic heart disease or to individuals who have established rheumatic heart disease to prevent the progression of disease and to prevent infective endocarditis.
For highly suspected acute rheumatic disease, secondary prophylaxis is usually given minimum 10 years or until age 21 (which ever is
longer), or until alternative diagnosis is confirmed.
Intramuscular injection of benzathine benzylpenicillin every three weeks (every four weeks in low-risk areas or low risk patients) is given.Oral penicillin is an alternative
Secondary prevention
Administering regular prophylactic antibiotics to individuals who have had an episode of acute rheumatic fever to prevent the development of rheumatic heart disease or to individuals who have established rheumatic heart disease to prevent the progression of disease and to prevent infective endocarditis.
For highly suspected acute rheumatic disease, secondary prophylaxis is usually given minimum 10 years or until age 21 (which ever is
longer), or until alternative diagnosis is confirmed.
Intramuscular injection of benzathine benzylpenicillin every three weeks (every four weeks in low-risk areas or low risk patients) is given.Oral penicillin is an alternative
Tertiary prevention Intervention in individuals with rheumatic heart disease to reduce symptoms and disability, and
prevent premature death
Tertiary prevention
Intervention in individuals with rheumatic heart disease to reduce symptoms and disability, and
prevent premature death
Dental review To prevent infective endocarditis due to infections (patients with rheumatic heart disease,are more prone to get infective endocarditis due to infections) Dental review
To prevent infective endocarditis due to infections (patients with rheumatic heart disease,are more prone to get infective endocarditis due to infections)

Management - Specific

Fact Explanation
Treatment of heart failure Generally responds to bed rest and steroids.But in severe symptoms diuretics,angiotensin converting enzyme inhibitors and digoxin may be used Treatment of heart failure
Generally responds to bed rest and steroids.But in severe symptoms diuretics,angiotensin converting enzyme inhibitors and digoxin may be used
Antibiotic prophylaxis For prevention of infective endocarditis.Intramuscular injection of benzathine benzylpenicillin every three weeks (every four weeks in low-risk areas or low risk patients) is given.Oral penicillin is an alternative.
For highly suspected acute rheumatic disease, secondary prophylaxis is usually given minimum 10 years or until age 21 (which ever is longer), or until alternative diagnosis is confirmed.
Antibiotic prophylaxis
For prevention of infective endocarditis.Intramuscular injection of benzathine benzylpenicillin every three weeks (every four weeks in low-risk areas or low risk patients) is given.Oral penicillin is an alternative.
For highly suspected acute rheumatic disease, secondary prophylaxis is usually given minimum 10 years or until age 21 (which ever is longer), or until alternative diagnosis is confirmed.
Surgery for rheumatic heart disease Balloon valvotomy (commissurotomy)
This technique is reserved almost entirely for stenosis of the mitral
valve
Surgery for rheumatic heart disease
Balloon valvotomy (commissurotomy)
This technique is reserved almost entirely for stenosis of the mitral
valve
Heart transplantation Heart transplantation for endstage rheumatic heart disease can achieve an acceptable long-term survival Heart transplantation
Heart transplantation for endstage rheumatic heart disease can achieve an acceptable long-term survival

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