Rheumatic heart disease occurs when attacks of ARF cause permanent scarring and damage to the valves of the heart. Normally, heart valves help move blood through the chambers of the heart with each beat. When valves have been damaged by RHD they cannot open and close normally, causing blood to move in the wrong direction. When this happens the heart cannot pump blood effectively, causing heart failure.
Rheumatic heart disease (RHD) is a preventable, treatable form of cardiovascular disease that affects over 32 million people around the world and claims 275,000 lives annually. It affects the world’s poorest, most vulnerable populations and imposes heavy costs on the health systems that can least afford it.
If left untreated, rheumatic heart disease can lead to heart valve damage, stroke, heart failure, and death. Treatment of advanced disease requires costly surgery unavailable in many parts of the world. In endemic countries, prevalence of this preventable disease is a stark measure of health system failure and inequality. RHD is the most commonly acquired heart disease in young people under the age of 25. It most often begins in childhood as strep throat. If left untreated, RHD may progress to serious heart damage that kills or debilitates adolescents and young adults, and makes pregnancy hazardous. Although virtually eliminated in Europe and North America, the disease remains common in Africa, the Middle East, Central and South Asia, the South Pacific, and in impoverished pockets of developed nations.
Who is at risk?
The biggest risk factor for developing RHD is having repeated episodes of ARF. This risk can be reduced by regular antibiotic medication. RHD usually begins in adolescence but can be diagnosed into adulthood. 80% of people living with RHD live in developing countries. Others live in vulnerable populations in developed settings.
Symptoms of RHD
There may be no symptoms in the early stages of RHD, this is sometimes called the asymptomatic or latent phase. It may be possible for doctors or health workers to check signs of early disease which people may not notice themselves. This may include:
- Heart murmurs heart through a stethoscope
- Changes in the way heart valves work may be seen on an heart scan (echocardiography)
The first symptoms of RHD are usually from heart failure. These may include:
- Fatigue (feeling tired)
- Feeling short of breath, this may be worse when exercising or when lying down.
Treatment
Treatment of RHD usually requires young people to have regular antibiotics which prevent further attacks of ARF and damage to heart valves. Penicillin is the most commonly used antibiotic and is often given as an injection every 3 – 4 weeks.
Medication may also be given to manage symptoms of heart failure or heart rhythm abnormalities. Anticoagulation medication to reduce the risk of blood clots may be needed. In some cases of advanced RHD heart surgery may be required.
Complications of RHD
Heart failure
The major cause of death and disability from RHD is heart failure. Over time, scarred and damaged heart valves make it impossible for the heart to pump blood effectively. Without a well-functioning heart, fluid builds up in the lungs and body, causing symptoms like breathlessness, swelling and fatigue. These symptoms tend to become worse over time without treatment.
Stroke
A ‘stroke’ occurs when a part of the brain does not receive adequate blood supply.
Strokes can be from clot which blocks a blood vessel (ischemic) or from a burst blood vessel (hemorrhagic). People with RHD are at risk of ischemic stroke because of blood clots which can form in the heart and subsequently block blood flow to parts of the brain.
Some people living with RHD need to take ‘blood thinning’ medication (anticoagulation) to reduce the risk of stroke.
Arrhythmia
Atrial fibrillation (AF) is an abnormal heart rhythm. People with RHD are at risk of AF because heart valve damage changes the shape of the heart and increased the risk of AF. AF tends to make heart failure worse, increasing shortness of breath, and may cause palpitations. AF also significantly increases the risk of stroke.
Endocarditis
Infective endocarditis (IE) is a bacterial infection on the valves of the heart. Valves that are already scarred or damaged by RHD are more likely to have IE than undamaged valves.
People with IE have fevers and the heart may be unable to pump blood effectively. It can be difficult to diagnose IE and, even when IE can be diagnosed, antibiotic treatment may be ineffective.
Minimising the risk of IE is an important part of managing RHD. The bacteria that cause IE tend to come from the mouth, so good dental hygiene is an important way to minimize risk. Giving prophylactic antibiotics before dental work and some other procedures is standard in many countries.
Complications in pregnancy
Women with RHD are at risk of significant illness or death during pregnancy and labour. The changes of pregnancy make the heart work harder. Hearts that have been damaged by RHD may not be able to adjust to these changes causing heart failure. The symptoms of heart failure may be confused with symptoms of late pregnancy and go untreated, causing cardiovascular collapse and death. Women who have received heart valve surgery and metal heart valves are at risk of serious bleeding from anticoagulation medication. These medications can also affect the developing baby.