Lecture Notes: Rheumatic Heart Disease (RHD)
1. Definition
Rheumatic Heart Disease (RHD) is a chronic cardiac condition resulting from Rheumatic
Fever (RF) — an inflammatory disease that occurs as a complication of untreated or
inadequately treated group A β-hemolytic streptococcal (GAS) pharyngitis (strep throat).
It causes progressive and permanent damage to the heart valves, particularly the
mitral and aortic valves, due to autoimmune inflammation and fibrosis.
It is most common among children (5–15 years old) in developing countries but its
complications manifest in adulthood.
Simplified Concept:
“Rheumatic fever inflames the heart; rheumatic heart disease scars it forever.”
2. Signs and Symptoms
A. General Manifestations (During Acute Rheumatic Fever)
Fever
Malaise and fatigue
Migratory polyarthritis (painful swelling of joints)
Subcutaneous nodules
Erythema marginatum (rash with pink rings on trunk or limbs)
Sydenham’s chorea (involuntary jerky movements)
B. Cardiac Manifestations (Progressing to RHD)
Dyspnea on exertion → due to pulmonary congestion
Orthopnea and paroxysmal nocturnal dyspnea (PND)
Palpitations due to atrial fibrillation
Chest pain (from valvular dysfunction)
Heart murmurs (most commonly mitral stenosis or mitral regurgitation)
Fatigue and weakness from decreased cardiac output
Peripheral edema and ascites (right-sided failure in advanced stages)
Cough with pink frothy sputum (if pulmonary edema is present)
C. Specific Valve Involvement
Valve Affected Manifestations
Mitral valve (most common) Dyspnea, cough, hemoptysis, opening snap, diastolic murmur
Aortic valve Angina, dizziness, syncope, systolic murmur
Tricuspid valve JVD, hepatomegaly, ascites, edema
3. Laboratory and Diagnostic Tests
Test Purpose / Findings
Throat Culture Detects Group A Streptococcus infection (initial cause)
Antistreptolysin-O (ASO) Titer Elevated levels indicate recent streptococcal infection
Erythrocyte Sedimentation Rate
Elevated — show systemic inflammation
(ESR) & C-Reactive Protein (CRP)
Complete Blood Count (CBC) ↑ WBC count (infection/inflammation)
Prolonged PR interval; shows arrhythmias (e.g., atrial
Electrocardiogram (ECG)
fibrillation)
Chest X-ray (CXR) Cardiomegaly, pulmonary congestion
Confirms valve lesions (mitral/aortic stenosis or
Echocardiogram (2D Echo)
regurgitation), chamber enlargement
Measures valve pressure gradients and severity of
Cardiac Catheterization
stenosis
Used to diagnose acute rheumatic fever (2 major or 1
Jones Criteria major + 2 minor criteria + evidence of streptococcal
infection)
4. Pathophysiology
Step-by-Step Mechanism:
1. Streptococcal Pharyngitis Infection:
o Group A β-hemolytic Streptococcus (GAS) infects throat.
2. Autoimmune Response:
o Body produces antibodies against streptococcal antigens.
o These antibodies cross-react with heart tissue (molecular mimicry), especially
myocardium and valves.
3. Inflammation of the Heart Layers (Pancarditis):
o Endocarditis → inflammation and scarring of valves (especially mitral and
aortic).
o Myocarditis → Aschoff bodies (granulomatous nodules).
o Pericarditis → friction rub, pericardial effusion.
4. Valve Damage and Fibrosis:
o Valves become thickened, deformed, and stenotic → blood flow obstruction and
regurgitation.
o This causes volume and pressure overload in cardiac chambers.
5. Chronic Cardiac Remodeling:
o Chamber dilation, hypertrophy, and decreased contractility.
o Leads to heart failure, arrhythmias, and pulmonary hypertension.
Summary Flowchart:
Strep throat → Rheumatic fever → Autoimmune inflammation → Valve scarring (RHD) →
Decreased cardiac efficiency → CHF & complications
5. Medical and Surgical Management
A. Medical Management
Goal Intervention Rationale
Eradicate Penicillin V or IM Benzathine Eliminates remaining bacteria to
Streptococcal Infection Penicillin G prevent recurrence
Anti-inflammatory
Aspirin, corticosteroids (Prednisone) Reduces inflammation and pain
Therapy
Control Heart Failure Diuretics (Furosemide), ACE Reduces preload and afterload,
Symptoms inhibitors, Digoxin improves cardiac output
Manage Arrhythmias Beta blockers, antiarrhythmic agents Controls rate/rhythm
Long-term Penicillin (monthly IM Prevents recurrent rheumatic
Secondary Prophylaxis
for 5–10 years or until age 21) fever
Warfarin (especially if atrial
Anticoagulants Prevents thromboembolic events
fibrillation present)
B. Lifestyle and Supportive Measures
Low-sodium diet to prevent fluid overload
Bed rest during acute inflammation
Avoid strenuous activity during recovery
Education on compliance with prophylactic antibiotics
C. Surgical Management
Procedure Indication / Purpose
Commissurotomy (valvulotomy) To open a stenotic (narrowed) valve
Valve Repair (valvuloplasty) Preserves native valve if possible
Valve Replacement (Prosthetic or Biologic) For severe deformity or regurgitation
Balloon Valvotomy Minimally invasive option for mitral stenosis
Heart Transplant In end-stage RHD with irreversible failure
6. Nursing Management
A. Nursing Assessment
Assess history of recurrent sore throat or rheumatic fever.
Monitor for signs of heart failure (dyspnea, edema, fatigue).
Evaluate vital signs, especially heart rate, rhythm, and presence of murmurs.
Assess activity tolerance and oxygen saturation.
Review medication adherence, especially antibiotics and anticoagulants.
B. Nursing Diagnoses
Decreased cardiac output related to valvular insufficiency
Activity intolerance related to imbalance between oxygen supply and demand
Ineffective tissue perfusion related to reduced cardiac pumping ability
Risk for infection related to chronic disease and valve damage
Knowledge deficit related to long-term management and prophylaxis
C. Nursing Interventions and Rationales
Nursing Intervention Rationale
Monitor vital signs and cardiac rhythm regularly Detect arrhythmias and heart failure early
Auscultate heart sounds for murmurs or friction
Identifies worsening valvular involvement
rubs
Position in semi-Fowler’s or high Fowler’s Promotes lung expansion and comfort
Administer medications as prescribed (antibiotics, Manages infection, fluid overload, and
diuretics, anticoagulants) clot prevention
Encourage rest and limit activity Reduces myocardial oxygen demand
Monitor intake/output and daily weights Detects fluid retention
Educate patient and family about prophylactic
Prevents recurrence of rheumatic fever
penicillin
Provide teaching about dental hygiene and
Prevents infective endocarditis
prophylaxis before dental/surgical procedures
Ensures monitoring of valve function and
Advise on lifelong cardiac follow-up
early detection of complications
D. Evaluation / Expected Outcomes
Patient remains free from recurrent infection.
Cardiac output is maintained within normal limits.
Patient demonstrates adherence to medication and follow-up regimen.
No signs of fluid overload or decompensated heart failure.
Verbalizes understanding of preventive measures and lifestyle modifications.
Summary Table: Rheumatic Heart Disease at a Glance
Aspect Key Points
Cause Autoimmune reaction after Group A Streptococcal throat infection
Mainly Affects Heart valves (mitral > aortic)
Early Signs Fever, joint pain, carditis, rash
Late Signs Murmurs, dyspnea, fatigue, CHF
Diagnostics Echo, ASO titer, Jones criteria
Treatment Antibiotics, anti-inflammatory, valve repair/replacement
Prevention Early treatment of strep throat, secondary prophylaxis