Define Rheumatic Heart Disease & Secondary Prophylaxis. Describe its clinical features, diagnosis, management and prevention.

Definition

• Rheumatic Heart Disease (RHD) is the chronic valvular damage that results from one or more attacks of acute rheumatic fever.
• It is a major cause of acquired heart disease and cardiac morbidity in children and young adults in developing countries.

Valves Affected

• The mitral valve is most commonly involved, followed by the aortic valve; the right-sided valves are rarely affected.
• Mitral regurgitation predominates in the acute/early stage; mitral stenosis develops later after recurrent attacks.

Clinical Features

• Depend on the valve lesion — exertional dyspnoea, palpitations, fatigue, and features of heart failure.
• Characteristic murmurs — a pansystolic murmur (mitral regurgitation) or a mid-diastolic murmur with a loud S1 (mitral stenosis).
• Complications — heart failure, atrial fibrillation, infective endocarditis, and systemic embolism.

Diagnosis

• Echocardiography is the key investigation (defines the valve lesion and severity); ECG and chest X-ray support it.

Secondary Prophylaxis (the Cornerstone of Prevention)

• Benzathine penicillin G, IM every 3–4 weeks — to prevent recurrent rheumatic fever and further valve damage (oral penicillin/erythromycin if injections are refused/allergic).
• Duration: ARF without carditis → 5 years or until age 21 (whichever is longer); with carditis but no residual disease → 10 years or until 21; with residual valve disease → up to 10 years after the last attack or until age 40, often lifelong.

Management of Established RHD

• Treat heart failure; anticoagulation for atrial fibrillation; infective-endocarditis awareness.
• Balloon valvotomy or valve surgery for significant stenosis/regurgitation.

Primary VS Secondary Prevention

• Primary prevention — prompt penicillin treatment of streptococcal sore throat to prevent the first attack of ARF.
• Secondary prevention — regular benzathine penicillin to prevent recurrences in a child who has already had ARF/RHD.