Rheumatic Heart Disease

Treat established rheumatic heart disease as an indication for secondary prevention of rheumatic fever, independent of whether the patient currently has pharyngitis symptoms or has already undergone valve replacement. Recurrent rheumatic fever worsens rheumatic valvular injury, and recurrent episodes may follow asymptomatic group A streptococcal infection despite treatment of symptomatic infections. jacc+1jacc2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelinesjacc2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines | JACC

At each visit, define the dominant actionable problem with transthoracic Doppler echocardiography: valve lesion severity, mitral regurgitation grade, pulmonary pressures, left atrial thrombus status when intervention is contemplated, ventricular function, and whether findings support referral to a Comprehensive Valve Center. Serial echocardiographic assessment of valve and left ventricular function is a core component of long-term rheumatic heart disease management. jacc+1jacc2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines | JACCScienceDirectMedical Management of Rheumatic Heart Disease - ScienceDirect

Escalate promptly when symptoms and noninvasive testing disagree about lesion severity. In symptomatic valvular heart disease, invasive cardiac catheterization for hemodynamic assessment is recommended when noninvasive testing is inconclusive or discordant with physical examination findings. jaccjacc2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

For patients with rheumatic heart disease, prescribe long-term antimicrobial prophylaxis rather than waiting to identify and treat each group A streptococcal episode. The ACC/AHA guideline lists benzathine penicillin G 1.2 million units intramuscularly every 4 weeks, penicillin V potassium 250 mg orally twice daily, sulfadiazine 1 g orally once daily, or a macrolide/azalide when the patient is allergic to both penicillin and sulfadiazine. jaccjacc2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

For documented rheumatic valvular heart disease, continue prophylaxis for at least 10 years or through age 40 years, whichever is longer. Consider lifelong prophylaxis when the patient remains at high risk of group A streptococcal exposure; prophylaxis remains required after valve replacement. jaccjacc2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Intramuscular benzathine penicillin G given every 3 to 4 weeks is described as the first-line secondary prophylaxis strategy. However, in severe rheumatic heart disease, concern that an injection-related event may precipitate cardiac compromise supports strong consideration of oral antibiotics when the risk-benefit assessment favors avoiding intramuscular administration. jaccjaccRheumatic Heart Disease: JACC Focus Seminar 2/4

Classify rheumatic mitral stenosis as severe when mitral valve area is 1.5 cm² or less. In an asymptomatic patient, elevated pulmonary artery systolic pressure above 50 mm Hg supports intervention rather than observation when valve morphology is favorable, mitral regurgitation is less than 2+, and no left atrial thrombus is present. jaccjacc2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines | JACC

Refer such patients to a Comprehensive Valve Center for percutaneous mitral balloon commissurotomy (PMBC). The same anatomic restrictions apply when new-onset atrial fibrillation is the trigger for considering PMBC in an otherwise asymptomatic patient with severe rheumatic mitral stenosis. jaccjacc2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines | JACC

Before PMBC, resolve the key exclusion branch: left atrial thrombus, at least moderate mitral regurgitation, or unfavorable valve morphology should redirect discussion away from routine balloon commissurotomy toward individualized structural and surgical evaluation. The guideline recommendations supporting PMBC explicitly require favorable anatomy, less than 2+ mitral regurgitation, and absence of left atrial thrombus. jaccjacc2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines | JACC

For warfarin, use indication-specific INR targets and frequent INR monitoring. The FDA label directs daily INR determinations during initiation until the INR is stable in the therapeutic range, followed by INR testing every 1 to 4 weeks; the labeled target for nonvalvular atrial fibrillation is INR 2.5, with a therapeutic range of 2.0 to 3.0. dailymed nlm nih+1dailymed nlm nihThese highlights do not include all the information needed to use WARFARIN SODIUM TABLETS safely and effectively. See full prescribing information for WARFARIN SODIUM TABLETS. WARFARIN SODIUM tablets, for oral useInitial U.S. Approval: 1954dailymed nlm nihWARFARIN SODIUM

Do not extrapolate the nonvalvular atrial fibrillation target automatically to every rheumatic valve scenario. The label notes that warfarin has not been fully evaluated in valvular disease associated with atrial fibrillation and mitral stenosis, although a moderate-intensity INR range of 2.0 to 3.0 may be used; management for prosthetic valves may require a higher INR target and addition of aspirin depending on valve type, position, and patient factors. dailymed nlm nih+1dailymed nlm nihwarfarin sodium tabletdailymed nlm nihWARFARIN SODIUM

Warfarin is contraindicated in pregnancy except for women with mechanical heart valves, and it crosses the placenta with risk of fetal hemorrhage and reported congenital malformations. Patients with rheumatic heart disease who may become pregnant therefore need preconception cardiology and obstetric assessment before anticoagulant selection or valve intervention planning. dailymed nlm nih+2dailymed nlm nihwarfarin sodium tabletdailymed nlm nihThese highlights do not include all the information needed to use WARFARIN SODIUM TABLETS safely and effectively. See full prescribing information for WARFARIN SODIUM TABLETS. WARFARIN SODIUM tablets, for oral useInitial U.S. Approval: 1954Wolters KluwerACOG Practice Bulletin No. 212: Pregnancy and... : Obstetrics & Gynecology

Use a structured recall system for injections or oral prophylaxis, anticoagulation monitoring when applicable, clinical review, and serial echocardiography. Rheumatic heart disease care frameworks emphasize patient registers to coordinate cardiac monitoring, follow-up appointments, and surgical waiting lists. ScienceDirectScienceDirectMedical Management of Rheumatic Heart Disease - ScienceDirect

At each cardiology review, reassess symptoms, rhythm, anticoagulation status, valve severity, ventricular function, and pulmonary pressures. Refer for catheter-based or surgical intervention when disease is severe or symptomatic; pharmacologic treatment of severe rheumatic heart disease has limited evidence for changing outcomes compared with timely structural intervention. ScienceDirectScienceDirectMedical Management of Rheumatic Heart Disease - ScienceDirect

For patients of reproductive potential, integrate preconception assessment rather than deferring risk review until pregnancy. Maternal cardiovascular disease is a leading contributor to pregnancy-related mortality in the United States, and rheumatic valve disease management may require coordinated antepartum and postpartum planning. Wolters KluwerWolters KluwerACOG Practice Bulletin No. 212: Pregnancy and... : Obstetrics & Gynecology