Rheumatic Heart Disease

Chronic rheumatic heart disease results from single or repeated attacks of rheumatic fever that produce rigidity and deformity of valve cusps, fusion of the commissures, or shortening and fusion of the chordae tendineae. Stenosis or insufficiency results, and the two often coexist. The mitral valve alone is affected in 50-60% of cases; combined lesions of the aortic and mitral valves occur in 20%; pure aortic lesions are less common. Tricuspid involvement occurs only in association with mitral or aortic disease in about 10% of cases. The pulmonary valve is rarely affected. A history of rheumatic fever is obtainable in only 60% of patients with rheumatic heart disease.

The first clue to organic valvular disease is a murmur. Physical examination permits accurate diagnosis in many cases, but echocardiography will reveal valve cusp thickening with decreased opening in stenosis, estimate the magnitude of regurgitation, and demonstrate the earliest stages of specific chamber enlargement.

Recurrences of acute rheumatic fever can be prevented (see above). The patient should also receive prophylactic antibiotics preceding dental extraction, urologic and surgical procedures, etc, to prevent endocarditis (Table 33-4). With mitral valve disease, it is important to identify the onset of atrial fibrillation to institute anticoagulation. The important findings in each of the major valve lesions are summarized in Table 10-1. The hemodynamic changes, symptoms, associated findings, and course have been discussed previously.

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McDonald M et al: Acute rheumatic fever: a chink in the chain that links the heart to the throat? Lancet Infect Dis 2004; 4:240.

Narula J et al: Diagnosis of active rheumatic carditis. Circulation 1999;100:1576.

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Stollerman GH: Rheumatic fever in the 21st century. Clin Infect Dis 2001;33:806.