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10 February, 2010

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Rheumatic heart disease

Rheumatic heart disease may develop after a single ‘bout’ of rheumatic fever or following repeated or prolonged illness with rheumatic fever. It usually occurs during childhood. Rheumatic heart disease causes damage to various structures of the heart including the valves, lining or muscle.

Rheumatic fever is caused by infection with the Group A streptococcus bacterium. A common example of this type of infection is ‘strep throat’.

Common in remote Aboriginal communities
The prevalence of rheumatic heart disease is high in remote Aboriginal and Torres Strait Islander communities. The risk of death from rheumatic fever and rheumatic heart disease in Indigenous communities is 20 times that of Australians in the general population.

Risk factors
Risk factors include poverty, overcrowding and reduced access to medical care. Rheumatic heart disease is incurable but treatment can manage the symptoms and reduce the risk of complications.

Symptoms
Rheumatic heart disease does not always cause symptoms. When it does, symptoms may include:

Chest pain
Heart palpitations
Breathlessness on exertion
Breathing problems when lying down (orthopnoea)
Waking from sleep with the need to sit or stand up (paroxysmal nocturnal dyspnoea)
Swelling (oedema)
Fainting (syncope).

Rheumatic fever explained
Without medical treatment, an infection with the Group A streptococcus bacterium can cause rheumatic fever. The untreated infection (such as ‘strep throat’) spreads throughout the body and causes inflammation. In addition to the heart, other vulnerable parts of the body include the brain, skin and joints.

Rheumatic fever is rare in Australia except among Aboriginal and Torres Strait Islander people, especially children, who live in remote areas. In many of these communities, group A streptococcal infections occur mostly in the skin. Research is continuing to understand the role of skin infection in rheumatic fever in these children.

Access to medical treatment may be limited, which is why cases of rheumatic fever often go undiagnosed and untreated. Rheumatic heart disease affects 17 in every 1,000 people living in Aboriginal and Torres Strait Islander communities in the Northern Territory, compared with two in 1,000 among the general Australian population in the same area.

The heart valves are commonly affected
The heart is a double pump with four chambers. Each chamber is sealed with a valve. The valves open and close in one direction only, so that the blood cannot flow backwards.

Rheumatic heart disease often involves damage to the heart valves. Typically, the damaged heart valve cannot open or shut properly. This interferes with the proper flow of blood through the heart. Without treatment, the damaged valve may continue to deteriorate. Complications include congestive heart failure, which means the heart is unable to pump blood effectively. The strain causes the heart to enlarge. This can result in some of the symptoms of rheumatic heart disease.

Diagnosis
Diagnosis may include:

Physical examination
Medical history – including evidence of past rheumatic fever or strep infection
Blood tests – to check for the presence of inflammation and past exposure to the Group A streptococcus bacterium
Chest x-ray – to check for enlargement of the heart or fluid on the lungs
Electrocardiogram – to check if the chambers of the heart have enlarged or if there is an abnormal heart rhythm (arrhythmia)
Echocardiogram – to check the heart valves for any damage or infection, and to check for evidence of muscle damage or cardiac (heart) failure.

Treatment
Treatment depends on the severity of rheumatic heart disease but may include:

Hospital admission
Injections of antibiotics to treat any lingering infection
Heart valve surgery to repair the damaged heart valves
Surgical replacement with a mechanical valve, in cases where the valve is severely damaged – ongoing medications to prevent blood clotting may be needed.

Management of complications
Medical treatment of rheumatic heart disease includes reducing the risk of complications. Options may include:

Regular check-ups with a cardiologist (heart specialist) to monitor the heart
Up-to-date influenza (flu) vaccinations
Urgent medical treatment, such as antibiotics, for any strep infections
Good dental hygiene, since oral bacteria entering the bloodstream can increase the risk of heart complications such as endocarditis (inflammation of the inner heart lining)
Antibiotics – may be given to some people before some dental or surgical procedures to prevent bacterial infection of the damaged areas of the heart (endocarditis)
Good prenatal care, since pregnancy can make rheumatic heart disease worse.

Prevention
Rheumatic heart disease is a complication of untreated rheumatic fever. People who have had rheumatic fever are at increased risk of developing rheumatic heart disease. Prompt diagnosis and treatment of rheumatic fever can prevent rheumatic heart disease. Medical treatment for a person who has had rheumatic fever may include low-dose antibiotics taken for a long time – perhaps for the rest of the person’s life, if the risk of rheumatic heart disease is high.

Ideally, rheumatic fever should be prevented. Antibiotic therapy (such as penicillin) to treat group A streptococcal infections such as strep throat can dramatically reduce the risk of rheumatic fever and its complication, rheumatic heart disease.

Where to get help

Your doctor
Cardiologist
Heart Foundation Tel. 1300 36 2787
HeartKids Victoria, Royal Children’s Hospital Melbourne Tel. (03) 9513 9030

Things to remember

Rheumatic heart disease causes damage to various structures of the heart including the valves, lining or muscle.
This condition may develop after repeated or prolonged illness with rheumatic fever.
The prevalence of rheumatic heart disease is high in remote Aboriginal and Torres Strait Islander communities.

You might also be interested in:
Aortic stenosis.
Heart arrhythmia and palpitations.
Heart conditions - angina.
Heart conditions - endocarditis.
Heart disease - enlarged heart.
Heart disorders (acquired) – children.
Heart explained.
Rheumatic heart disease.

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