Unveiling Rheumatic Heart Disease – Risks, Signs, Diagnosis, and Empowered Solutions

Key points for Rheumatic Heart Disease

• Rheumatic heart disease occurs when the heart valves are permanently damaged because of rheumatic fever.
• Rheumatic fever is a kind of sickness that can affect many parts of the body, especially the heart.
• If infections caused by strep bacteria aren’t treated well, they can raise the chances of getting rheumatic fever. Kids who often get strep throat are at the most risk for this heart problem.
• Getting treated for streptococcal throat infection can prevent getting RHD.
  Doctors look for recent cases of strep infections or rheumatic fever to find out if someone has rheumatic heart disease.

Risk Factors for Rheumatic Heart Disease

Here are some of the key risk factors for rheumatic heart disease:

1. Untreated Strep Infections: The primary risk factor for RHD is inadequate treatment or lack of treatment for streptococcal infections. When these infections are not promptly and properly treated with antibiotics, the bacteria can trigger an abnormal immune response in some individuals, leading to inflammation and damage to the heart valves.
2. Repeated Infections: Recurrent episodes of streptococcal infections, especially in susceptible individuals, increase the risk of developing RHD. Multiple episodes of untreated or poorly managed strep infections can heighten the chances of heart complications.
3. Age and Gender: RHD is more common in children and young adults, particularly between the ages of 5 and 15. Females also tend to be at a slightly higher risk than males. particularly in areas where access to healthcare and antibiotics is limited.
4. Socioeconomic Factors: Socioeconomic factors, such as poor living conditions, overcrowding, limited access to healthcare, and inadequate nutrition, can increase the likelihood of exposure to streptococcal infections. It hinders the prompt and effective treatment of these infections, contributing to the risk of RHD.
5. Environmental Factors: Environmental factors, such as living in densely populated areas with poor sanitation, might contribute to the spread of streptococcal infections, increasing the risk of RHD.

Symptoms of Rheumatic Heart Disease

A streptococcal throat infection usually causes the clinical signs of acute rheumatic fever (ARF) to appear two to three weeks later. RHD symptoms may not show up for several years. The kind and extent of the damage to the heart valves and which heart valves are impacted determine the symptoms when they appear. Common symptoms of rheumatic heart disease include:

1. Shortness of Breath: As heart valve damage progresses and the heart’s pumping efficiency decreases, individuals with RHD may experience difficulty breathing, especially during physical activities or when lying flat.
2. Fatigue: Reduced heart function can lead to decreased blood flow to the body’s organs and tissues, resulting in persistent fatigue and weakness.
3. Palpitations: Irregular heartbeats or palpitations can occur due to valve abnormalities and changes in the heart’s electrical conduction system.
4. Chest Pain: Some individuals with RHD may experience chest discomfort or pain, particularly when the heart’s blood supply is inadequate or when the heart is strained due to valve issues.
5. Swelling: Swelling of the feet, ankles, or legs (edema) can develop as the heart’s pumping efficiency decreases, causing fluid buildup in the body’s lower extremities.
6. Coughing: A persistent cough may develop, often accompanied by frothy or pink-tinged sputum, which can indicate fluid accumulation in the lungs (pulmonary congestion).
7. Lightheadedness or Fainting: Insufficient blood flow to the brain can lead to dizziness, lightheadedness, or even fainting episodes.
8. Weight Gain: Fluid retention due to heart failure can lead to unexplained weight gain over a short period.
9. Joint Pain: In some cases, joint pain and inflammation (similar to symptoms of rheumatic fever) might occur, particularly if there is ongoing immune system activity.
10. Skin Changes: Skin changes such as a bluish tint to the skin (cyanosis) or the development of small, painless nodules (called subcutaneous nodules) under the skin can occur in more severe cases of RHD.

Diagnosis of Rheumatic Heart Disease

Diagnosing RHD involves a combination of medical history assessment, physical examination, imaging tests, and sometimes laboratory investigations. The diagnosis of rheumatic heart disease is discussed below:

1. Medical History and Physical Examination: Individuals with suspected RHD often have a history of rheumatic fever or recurrent streptococcal infections. During a physical examination, a murmur may be detected. The murmur results from blood leaking around damaged heart valves affected by RHD.
2. Streptococcal Infection Testing: People with RHD may have had a recent or current streptococcal infection. Thus, streptococcal testing is of utmost importance. A swab of the throat can be cultured to identify the presence of streptococcus bacteria.
3. Blood Test: Blood tests may be performed to measure certain markers of inflammation (such as C-reactive protein or erythrocyte sedimentation rate) and to check for streptococcal antibodies. Elevated levels of these markers can indicate ongoing inflammation and might suggest a recent streptococcal infection.
4. Chest X-ray: A chest X-ray can provide information about the size and shape of the heart. In cases of advanced RHD, the heart might be enlarged, and there could be signs of fluid accumulation in the lungs.
5. Electrocardiogram (ECG): An ECG records the electrical activity of the heart. It can help identify any irregularities in the heart’s rhythm or conduction system that might be related to RHD.
6. Echocardiogram: An echocardiogram is a key diagnostic tool for RHD. It uses sound waves to create detailed images of the heart’s structure and function. It can help identify any damage to the heart valves, such as thickening, narrowing, or leakage, which are common characteristics of RHD.
7. Cardiac MRI: In some cases, your doctor may recommend obtaining a cardiac MRI for more detailed images of the heart’s structure and function. This can provide additional information about the extent of valve damage.

Treatment and Management of Rheumatic Heart Disease

Treating RHD involves addressing the underlying cause, managing symptoms, and preventing further complications. The goals of treatment include:

1. Antibiotics: Acute rheumatic fever, which is the precursor to RHD, is caused by a streptococcal infection. Antibiotics like penicillin or other appropriate antibiotics treat the active infection and prevent further streptococcal infections, which could exacerbate the condition.
2. Anti-inflammatory medications: In the acute phase of rheumatic fever, anti-inflammatory medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) are often prescribed to reduce inflammation and manage symptoms like fever, pain, and joint swelling.
3. Heart Failure Management: For individuals with severe valve damage or other heart complications resulting from RHD, medications such as diuretics to reduce fluid retention, ACE inhibitors to lower blood pressure and improve heart function, and beta-blockers to slow down heart rate and reduce strain on the heart might be prescribed to manage heart failure symptoms.
4. Surgery: In cases where the heart valves are significantly damaged and not functioning properly, surgical intervention might be necessary. Valve repair or replacement surgeries are common procedures to address this issue and improve heart function.
5. Preventive Antibiotics: Individuals with rheumatic fever or existing heart valve damage due to RHD are typically advised to take prophylactic antibiotics before certain medical or dental procedures. This is to prevent the risk of bacterial endocarditis, an infection of the heart lining or valves.

Complications of Rheumatic Heart Disease

RHD can lead to several complications due to the damage it causes to the heart valves and other heart structures. Some of the complications of rheumatic heart disease include:

1. Valvular Heart Disease: RHD primarily affects the heart valves, leading to valvular damage. The valves can become thickened, scarred, or distorted, impairing their ability to open and close properly. This can result in conditions such as:

• Mitral Stenosis: The mitral valve becomes narrowed, making it difficult for blood to flow from the left atrium to the left ventricle.
• Mitral Regurgitation: The mitral valve doesn’t close properly, causing blood to leak back into the left atrium.
• Aortic Stenosis: The aortic valve becomes narrowed, obstructing the flow of blood from the left ventricle to the aorta.
• Aortic Regurgitation: The aortic valve doesn’t close properly, causing blood to flow back from the aorta into the left ventricle.

2. Heart Failure: As the valve damage worsens, the heart’s ability to pump blood efficiently can be compromised, leading to heart failure. This can result in symptoms like shortness of breath, fatigue, fluid retention, and swelling.

3. Infective Endocarditis: The damaged heart valves can create an environment where bacteria are more likely to infect the heart lining or valves, leading to infective endocarditis. This is a serious and potentially life-threatening infection.

4. Arrhythmias: Irregular heart rhythms, or arrhythmias, can occur due to the changes in the heart’s structure and function caused by RHD. These can range from mild palpitations to more severe rhythm disturbances.

5. Pulmonary Hypertension: Over time, the increased strain on the heart due to valve damage can lead to high blood pressure in the pulmonary arteries which can affect the lungs and heart function.

6. Stroke: In some cases, blood clots can form on the damaged heart valves. If a clot dislodges and travels to the brain, it can cause a stroke.

7. Embolism: Blood clots can also travel to other parts of the body, causing blockages in blood vessels (embolism) and potentially affecting various organs.

Prevention of Rheumatic Heart Disease

Preventing RHD primarily involves the prevention and prompt treatment of streptococcal infections. Here are key strategies for preventing RHD:

1. Prompt Treatment of Strep Infections: It’s crucial to promptly and effectively treat streptococcal infections, such as strep throat, with appropriate antibiotics. Treating these infections within ten days of symptom onset reduces the risk of developing rheumatic fever.
2. Complete Antibiotic Course: Ensure that antibiotic treatments for streptococcal infections are completed as prescribed by a healthcare professional to fully eradicate the bacteria.
3. Early Detection and Treatment of Rheumatic Fever: Recognizing and promptly treating rheumatic fever is essential. Treating rheumatic fever with anti-inflammatory medications (like aspirin or corticosteroids) and antibiotics can help prevent further heart damage that could lead to RHD.
4. Regular Antibiotic Prophylaxis: Individuals who have had rheumatic fever are often prescribed ongoing antibiotics as prophylaxis to prevent recurrent streptococcal infections and minimize the risk of developing RHD.
5. Improving Access to Healthcare: Ensuring access to healthcare, especially in regions with high incidence rates of streptococcal infections and rheumatic fever, is crucial. This includes access to healthcare facilities for diagnosis, treatment, and follow-up care.
6. Health Education and Awareness: Educating communities, healthcare professionals, and individuals about the importance of seeking medical care for streptococcal infections, completing antibiotic courses, and recognizing symptoms of rheumatic fever can aid in early intervention and prevention.
7. Promoting Hygiene and Sanitation: Implementing measures to improve hygiene, sanitation, and living conditions can help reduce the spread of streptococcal infections in communities.

Questions for your doctor

1. Is RHD curable, or can it be reversed through treatment?
2. How often should I have follow-up appointments and monitoring for my condition?
3. Are there any lifestyle changes or self-care measures that can help manage RHD symptoms and prevent complications?
4. Can you guide me on preventing recurrent episodes of rheumatic fever and RHD?
5. What should I do if I experience a flare-up or new RHD-related symptoms?
6. Are there any specific dietary recommendations or restrictions for individuals with Rheumatic Heart Disease?
7. How does RHD impact physical activity and exercise, and are there any limitations or precautions I should follow?

References

1. https://www.ncbi.nlm.nih.gov/books/NBK538286/
2. https://world-heart-federation.org/what-we-do/rheumatic-heart-disease/