Rheumatic Heart Disease 

 

Definition:

  • Cardiac inflammation and scarring triggered by autoimmune reaction.

  • The most common form of long-term damage from scarring and fibrosis of the valve tissue of the heart is mitral stenosis.

  • Symptoms of the valvular dysfunction manifest 10 to 30 years after ARF has subsided.

 

Epidemiology:

  • Accourding to a study of the western district, the prevelance is 24 in 10,000.

    • Females > Males.

    • More common in rural areas.

  • Estimated number of 12 million individuals suffered from RF and RHD worldwide.

 

Pathophysiology:

  1. Acute rheumatic heart disease:

    • Pericarditis, myocarditis, and endocarditis (common from the inside-out).

    • Endocarditis typically affects the mitral and aortic valves (fibrin vegetations)

    • May cause left atrial thickening (McCallum plaques).

    •  Myocardium will have Aschoff bodies (fibrinoid necrosis surrounded by Macrophages).

  2. Chronic rheumatic heart disease:

    • Primary manifestation is valvular stenosis.

    • Aschoff bodies are replaced with fibrous scar in CRHD.

    • Acute interstitial valvulitis -> valvular edema (untreated) -> valve thickening, fusion, calcium deposition.

    • Chordae tendineae -> shorten, thicken, or fuse (adding to the damage of valves or causing regurgitation of an otherwise healthy valve).

    • The mitral, aortic, tricuspid, and pulmonic valves are affected, in order.

    • Regurgitation and stenosis are the usual effects on the mitral and tricuspid valves; the aortic valve generally becomes regurgitant initially and stenotic much later. 

Clinical Presentation:

  • Mitral valves stenosis and/or regurgitation.

    • Symptoms of MS

      • ​Breathlessness.

      • Chest pain.

      • Cough and/or Hemoptysis.

      • Fatigue.

      • Edema and ascites.

      • Palpitation.

      • Thromboembolic complications (stroke, ischemic limb)

    • Signs of MS:

      • Mitral facies.

      • Atrial fibrillation.

      • Mid-diastolic rumble at the apex

    • Other valves stenosis and/or regurgitation.

    • Infective endocarditis.

    • Congestive heart failure.

↑Heart rate -> ↓diastole time -> left atrial pressure↑, so pregnancy and exercise are not well-tolerated. 

Study guide:

Study guide:

Diagnosis:

  • Chest X-ray to check enlargement of the heart, pulmonary congestion, pulmonary edema and pulmonary hypertension signs.

  • ECG to check for ventricular hypertrophy, AF, P wave changes.

  • Echocardiography to check the valve, orifice size, diastolic filling, chamber enlargement.

  • Doppler to check the pressure gradient, arterial pressure, and ventricular function. o Cardiac catheterization to confirm the diagnosis. 

Management:

  • Life style modification (smoking cessation, reduce alcohol consumption).

  • Medications:

    • Warfarin:

      • The only standard anticoagulation so far with mechanical valve.

      • Teratogen. Therapeutic range is achieved by monitoring INR.

    • Antibiotics prior to surgeries or dental work.

    • Long-term antibiotic to prevent a recurrence of GAS infections.

  • Surgical (valve repair or replacement). 

References:

​Audio recording:

Read by: Khalid Abdullah Alkenaa


Directed by: ​Tariq Ayman Jawadi


Audio production: Bayan Alzomaili

Written by:     Lama Al Luhidan


Reviewed by:    Roaa Amer


Format editor:  Roaa Amer

Web Publisher: Bayan Alzomail