Rheumatic Heart Disease

About Rheumatic Heart Disease, definition, etiology, clinical features, diagnosis and management.

1. Neelu Aryal Msc Nursing 2 nd year RHEUMATIC HEART DISEASE

2. INTRODUCTION Rheumatic fever is a diffuse inflammatory disease characterized by a delayed response to an infection by group A beta-hemolytic streptococci (GAS) in the tonsilopharyngeal area, affecting the heart, joints, central nervous system, skin and subcutaneous tissues. It is thought that 40-60% of patients with ARF will go on to developing RHD.

3. DEFINITION Rheumatic heart disease is a chronic condition resulting from rheumatic fever which involves all the layers of the heart (i.e. pancarditis ) and is characterized by scarring and deformity of the heart valves. The commonest valves affecting are the mitral and aortic, in that order. However all four valves can be affected.

4. INCIDENCE Rheumatic fever is principally a disease of childhood, with a median age of 10 years, although it also occurs in adults (20% of cases). Rheumatic fever occurs in equal numbers in males and females, but the prognosis is worse for females than for males. The disease is seen more commonly in poor socio-economic strata of the society living in damp and overcrowded place.

5. INCIDENCE( contd …) Common in the developing countries like India, Pakistan. The incidence of RF in Developing countries is 27-100/1 lac /yr ( G.S.Sainani 2006) The incidence of rheumatic fever (RF) varies from 0.2 to 0.75/1000/ year in school children 5–15 years of age (2001 Govt. Census) (Anil Grover,Padamavati S et al, et.al INJ 2002).

6. ETIOLOGY Group A beta-hemolytic streptococcus. Rheumatic fever  

7. RISK FACTORS Poor socio-economic status : People who are poor and belongs to low socio-economic conditions are prone to get Rheumatic heart disease. Over-crowding : People who are living in a slum or damp area are more prone to get Rheumatic heart disease. Age : It appears most commonly in children between the age of 5 to 15 years.

8. RISK FACTORS( contd …) Climate and season : It occurs more in the rainy season and in the cold climate. Upper respiratory tract infection : Rheumatic fever is an outcome of upper respiratory tract infection with group A beta-hemolytic streptococcus.

9. RISK FACTORS( contd …) Previous history of Rheumatic fever : The client with previous history of Rheumatic fever are at high risk to develop Rheumatic heart disease. Genetic predisposition : Rheumatic heart disease shows familier tendancy .

10. PATHOPHYSIOLOGY

11. CLINICAL MANIFESTATIONS Major manifestations Carditis Polyarthritis Chorea Erythema marginatum Subcutaneous nodules

12. MAJOR MANIFESTATIONS( contd …) Carditis

13. MAJOR MANIFESTATIONS( contd …) Arthritis

14. MAJOR MANIFESTATIONS( contd …) Chorea

15. MAJOR MANIFESTATIONS( contd …) Erythema marginatum

16. MAJOR MANIFESTATIONS( contd …) Subcutaneous nodules

17. Minor manifestations include: Fever associated with weakness, malaise, weight loss and anorexia Arthralgia

18. Laboratory findings Positive throat culture for group A beta-hemolytic streptococci.

19. Laboratory findings( contd …) Elevated acute phase reactants: Erythrocyte sedimentation rate C-reactive protein Leukocytosis

20. Laboratory findings( contd …) Prolonged P-R interval

21. DIAGNOSTIC EVALUATIONS A diagnosis of rheumatic heart disease is made after confirming antecedent rheumatic fever. The modified Jones criteria (revised in 1992) provide guidelines for the diagnosis of rheumatic fever.

22. JONES CRITERIA 2 major or 1 major and 2 minor

23. Jones’ criteria for the diagnosis of Rheumatic fever Major manifestations Carditis Polyarthritis Chorea Erythema marginatum Subcutaneous nodules

24. Minor manifestations a ) Clinical findings Previous rheumatic fever or rheumatic heart disease. Arthralgia Fever associated with weakness, malaise, weight loss and anorexia

25. b) Laboratory findings Elevated ESR, C-reactive protein and Leukocytosis ECG and echocardiogram to confirm rhythm problems and structural changes (prolonged P-R interval). Chest X-ray shows enlarged heart.

26. c) Evidence of Group A streptococcal infection Positive throat culture for strep A Elevated or rising anti-streptococcal antibody titer Recent scarlet fever

27. IMAGING STUDIES Chest roentgenography : Cardiomegaly , pulmonary congestion, and other findings consistent with heart failure may be seen on chest radiography.

28. Doppler-echocardiogram In acute rheumatic heart disease, Doppler-echocardiography identifies and quantitates valve insufficiency and ventricular dysfunction.

29. In chronic rheumatic heart disease, echocardiography may be used to track the progression of valve stenosis and may help determine the time for surgical intervention.  

30. HEART CATHETERIZATION In acute rheumatic heart disease, this procedure is not indicated. With chronic disease, heart catheterization has been performed to evaluate mitral and aortic valve disease and to balloon stenotic mitral valves.

31. ON ECG Sinus tachycardia most frequently accompanies acute rheumatic heart disease. Alternatively, some children develop sinus bradycardia from increased vagal tone. Patients with rheumatic heart disease also may develop atrial flutter, multifocal atrial tachycardia, or atrial fibrillation from chronic mitral valve disease and atrial dilation.

32. HISTOLOGIC FINDINGS Pathologic examination of the insufficient valves may reveal verrucous lesions at the line of closure. Aschoff bodies ( perivascular foci of eosinophilic collagen surrounded by lymphocytes, plasma cells, and macrophages) are found in the pericardium, perivascular regions of the myocardium, and endocardium .

33. Anitschkow cells are plump macrophages within Aschoff bodies. In the pericardium, fibrinous and serofibrinous exudates may produce an appearance of "bread and butter" pericarditis .

34. MEDICAL MANAGEMENT 1. Eradicate infection Preventive and prophylactic therapy is indicated after rheumatic fever and acute rheumatic heart disease to prevent further damage to valves. Primary prophylaxis (initial course of antibiotics administered to eradicate the streptococcal infection) also serves as the first course of secondary prophylaxis (prevention of recurrent rheumatic fever and rheumatic heart disease). An injection of 0.6-1.2 million units of benzathine penicillin G intramuscularly every 4 weeks is the recommended regimen for secondary prophylaxis for most US patients.

35. Administer the same dosage every 3 weeks in areas where rheumatic fever is endemic, in patients with residual carditis , and in high-risk patients. Continue antibiotic prophylaxis indefinitely for patients at high risk ( eg , health care workers, teachers, daycare workers) for recurrent GABHS infection. Patients with rheumatic fever with carditis and valve disease should receive antibiotics for at least 10 years or until age 40 years.

36. Patients with rheumatic heart disease and valve damage require a single dose of antibiotics 1 hour before surgical and dental procedures to help prevent bacterial endocarditis . Patients who had rheumatic fever without valve damage do not need endocarditis prophylaxis. Do not use penicillin, ampicillin , or amoxicillin for endocarditis prophylaxis in patients already receiving penicillin for secondary rheumatic fever prophylaxis (relative resistance of PO streptococci to penicillin and aminopenicillins .

37. Alternate drugs recommended by the American Heart Association for these patients include PO clindamycin (20 mg/kg in children, 600 mg in adults) and PO azithromycin or clarithromycin (15 mg/kg in children, 500 mg in adults).

38. 2. Maximize cardiac output Corticosteroids are used to treat carditis , especially if heart failure is evident. If heart failure develops, treatment, including ACE inhibitors, beta blockers and diuretics, is effective.

39. 3. Promote comfort Client with arthritic manifestations obtain relief with salicylates . Bed rest is usually prescribed to reduce cardiac effort until evidence of inflammation has subsided.

40. SURGICAL MANAGEMENT

41. When heart failure persists or worsens after aggressive medical therapy for acute rheumatic heart disease, surgery to decrease valve insufficiency may be life-saving. Forty percent of patients with acute rheumatic heart disease subsequently develop mitral stenosis as adults. Cummisurotomy can be done to widen the valve.

42. In patients with critical stenosis , mitral valvulotomy , percutaneous balloon valvuloplasty , or mitral valve replacemen t may be indicated. Due to high rates of recurrent symptoms after annuloplasty or other repair procedures, valve replacement appears to be the preferred surgical option

43. NURSING MANAGEMENT

44. Nursing diagnosis Pain related to inflammatory response in the joints.   Objectives: The client verbalizes increased comfort as evidenced by reports of reduced discomfort, expression of joint pain reduction, relaxed body posture and a calm facial expression.

45. Interventions Assess the level of pain, duration, intensity and frequency of pain. Complete bed rest and provide comfortable position. Provide diversional therapy and psychological support. Administer analgesics as needed.

46. Nursing diagnosis Decreased cardiac output related to valve dysfunction or HF.   Objectives: client increases cardiac output as evidenced by regular cardiac rhythm, heart rate, blood pressure, respiration and urine output within normal limit.  

47. Interventions Assess the symptoms of heart failure and decreased cardiac output including diminished quality of peripheral pulses, cool skin and extremities, increased respiration, increased heart rate, neck vein distention and presence of edema. Assess for heart sounds. Monitor intake and output. Provide bed rest. Administration of cardiac glycosides as prescribed. Administration of antibiotics to reduce infection.

48. Nursing diagnosis Knowledge deficit related to disease condition and long term treatment.   Objectives : Patient gains adequate knowledge as evidenced by explaining disease condition, recognizing need for medication, understanding treatment.

49. Intervention Assess the clients level of knowledge. Assess the client’s ability to learn. Explain about disease condition and about prophylactic treatment of antibiotics. Clarify the clients doubt clearly.

50. Nursing diagnosis Anxiety related to disease condition and heart failure   Objectives : clients shows maximum reduction of anxiety.

51. Interventions Assess the clients level of anxiety. Clarify the doubts of the clients by using non medical terms and calm, slow speech. Explain all activities, procedures and issues that involves the client. Explain about the disease conditions and prophylactic treatment. Provide anxiolytics as prescribed.

52. BIBLIOGRAPHY Black JM, Hawks JH. Medical surgical nursing. 8 th ed.vol-2. Elsevier; p.1396-1401 Lewis, Heitkemper , Dirksen O’Brien, Bucher. Medical surgical nursing.7 th ed.New Delhi.Elsevier;p . 875-82 URL :https:// en.wikipedia.org /wiki/ Rheumatic_fever URL: http:// www.slideshare.net /miel9156/rheumatic-heart-disease-3264045 URL: http:// www.powershow.com /view/3d4797-MWI0M/ Rheumatic_heart_disease_RHD_powerpoint_ppt_presentation URL:http:// gmch.gov.in / estudy /e%20lectures/Pathology/cvs5%20RF.pdf

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