Exploring Clinical Features of Rheumatic Heart Disease

Rheumatic heart disease (RHD) is a long-term condition caused by damage to the heart valves from rheumatic fever. This condition is often caused by untreated or inadequately treated group A streptococcal infections like strep throat or scarlet fever. The autoimmune response during rheumatic fever causes inflammation, leading to valve damage and functional disorders such as heart failure or arrhythmias.

Read further to explore its clinical features, diagnosis, treatment options, and strategies for prevention and management.

Aetiology and Risk Factors

RHD is preceded by rheumatic fever that is caused by untreated Group A streptococcal infections. These infections make the body’s immune system swell, and they affect the heart, limbs, skin and brain. RHD has a characteristic feature of chronic valve damage, and repeated manifestations of rheumatic fever increase the risk of chronic valve disease.

Some of the risk factors of RHD include:

• Living in developing countries where health standards are poor.

• Limited access to healthcare and treatment for streptococcal infections.

• Poor hygiene, cramped living conditions, and overcrowded environments.

• Residing in remote areas with limited access to early medical intervention.

• Age factor, for instance, children and teenagers aged from 5 to 15 are more susceptible to it.

Pathophysiology of RHD

RHD is rooted in the immune system's response to streptococcal infections, with devastating effects on the heart’s structure and function.

During rheumatic fever, antibodies produced to fight the streptococcal bacteria cross-react with heart tissues, particularly in the valves. This autoimmune response causes inflammation, scarring, and fibrosis, progressively impairing valve function. The mitral and aortic valves are most commonly affected, leading to stenosis (narrowing) or regurgitation (leakage). Valve dysfunction increases the heart’s workload, contributing to complications such as heart failure, arrhythmias, and an elevated risk of stroke.

Clinical Presentation

Rheumatic heart disease (RHD) often manifests with a range of symptoms depending on the severity of valve damage and disease progression. Common symptoms include:

• Fatigue: Feeling tired or weak, even after minimal exertion

• Shortness of breath: Feeling shortness of breath after any physical activity 

• Chest pain: As a result of strain on the heart caused by valve damage

• Swelling: In the legs or ankles due to fluid retention

As RHD progresses, the signs become more pronounced and indicative of advanced complications. Such signs include:

• Extreme shortness of breath: Even when at rest, due to heart failure

• Palpitations: Irregular heart rhythms can cause the sensation of a racing or fluttering heart

• Recurrent respiratory infections: Frequent lung infections due to reduced heart function

In extreme cases, individuals may experience symptoms of heart failure. These signs are:

• Persistent fatigue: Consistently feeling tiredness, even with minimal activity

• Significant fluid retention: Notable swelling in several parts of the body

• Reduced tolerance for physical activity: Inability to engage in physical exertion due to heart inefficiency

Diagnosis of RHD

Accurate diagnosis of RHD begins with a detailed clinical examination and medical history. Physicians assess past occurrences of rheumatic fever, including symptoms such as joint pain, fever, or a history of untreated strep infections. During the physical exam, a stethoscope is used to detect heart murmurs, which often indicate valve abnormalities caused by RHD.

Diagnostic tests and imaging are crucial for confirming the presence and extent of valve damage. Some of the diagnostic methods include:

• Echocardiography: The gold standard for diagnosing RHD that provides detailed images of valve structure and function. 

• Electrocardiograms (ECG): A diagnostic method used to assess irregular heart rhythms

• Chest X-rays: Another method that helps detect an enlarged heart or fluid in the lungs.

• Blood tests: Tests conducted to identify markers of inflammation or a recent streptococcal infection.

Together, these diagnostic tools provide a comprehensive understanding of the disease

Treatment Options

RHD treatment primarily focuses on palliative care, aiming to control symptoms and prevent complications. However, in severe cases, recovery of cardiac function may require a combination of medications and surgical interventions.

Medications are the main tools pointing to the stabilisation and treatment of the progression of the disease.

• Chemoprophylaxis: Given to prevent recurrent streptococcal infections.

• Anti-inflammatory drugs: Used to treat inflammation during active rheumatic fever.

• Diuretics: Prescribed to manage oedema (fluid retention).

• Beta-blockers: Help manage hypertension and reduce strain on the heart.

• Anticoagulants: May be necessary if the valves or heart rate are severely affected.

If the condition is severe, then surgical Interventions may be required as well, including:

• Valve repair: This involves fixing the damaged valve to restore its function.

• Valve replacement: The damaged valve is replaced with a mechanical or biological valve.

Complications of RHD

RHD can cause serious further consequences that negatively affect the quality of life and overall cardiovascular health.

• The most frequent comorbidity involves the valves of the heart: the mitral and aortic, which are mostly affected by the disease. Chronic inflammation results in stenosis (narrowing) or regurgitation (leakage), the indices that affect the normal pumping of blood by the heart. These valve abnormalities can also lead to arrhythmias and blood clots, thus complicating the condition.

• Another complication of RHD is heart failure. Since the heart is tasked with pumping blood at a higher effort due to the non-functioning of its valves, its muscles get compromised and thus cause breathlessness, fatigue and oedema. 

• Other complications include infective endocarditis, which involves infection of damaged valves, and stroke, which occurs when blood clots go to the brain.

Prognosis and Long-term Management

The prognosis for individuals with rheumatic heart disease (RHD) largely depends on the extent of valve damage, access to timely treatment, and adherence to long-term care. Managing chronic symptoms is a critical component of living with RHD.

• Regular use of prescribed medications such as diuretics, beta-blockers, or anticoagulants helps alleviate symptoms like fluid retention, irregular heartbeats, and fatigue. Long-term antibiotic prophylaxis remains essential to prevent recurrent rheumatic fever and additional valve damage.

• Regular medical check-ups, including echocardiograms and blood tests, allow for the monitoring of disease progression and adjustment of treatment plans as necessary.

• Lifestyle modifications, such as adopting a heart-healthy diet, engaging in moderate physical activity, and avoiding tobacco and alcohol, play a crucial role in improving overall cardiovascular health.

Combining consistent medical management with proactive lifestyle changes helps individuals with RHD lead a better quality of life while minimising complications.

Prevention Strategies

Preventing RHD involves a combination of public health measures and targeted interventions for at-risk populations.

• Timely treatment of Group A streptococcal infections, such as strep throat, with antibiotics can prevent the onset of rheumatic fever.

• Public awareness campaigns about the importance of recognising and treating strep infections are essential in high-risk communities.

• Additionally, improving hygiene, reducing overcrowding, and ensuring access to healthcare are critical for controlling the spread of streptococcal infections, particularly in resource-limited settings.

For individuals who have experienced rheumatic fever, long-term antibiotic prophylaxis prevents recurrent episodes and reduces the risk of heart valve damage.

Conclusion

Rheumatic heart disease is a preventable and manageable condition that arises from untreated or poorly managed streptococcal infections. Early recognition of symptoms, effective treatment of rheumatic fever, and consistent long-term management are essential to reducing the progression and complications of RHD. Public health measures and targeted interventions remain critical in addressing the disease’s prevalence in high-risk populations.

Therefore, proactive approaches to detection, care, and prevention ensure better heart health for those at risk of or living with RHD