Rheumatic Heart Disease: Causes, Symptoms, Diagnosis, and Treatment
Introduction
Rheumatic heart disease (RHD) is a long-term, serious complication of rheumatic fever, an inflammatory condition that develops after an untreated or inadequately treated streptococcal throat infection (caused by Group A Streptococcus bacteria). It primarily affects the heart valves, leading to permanent damage that can disrupt normal blood flow through the heart.
RHD remains a major cause of cardiovascular disease in developing countries and is a preventable condition when detected early. Understanding how it develops, its symptoms, and available treatments is essential to reducing its impact.
What Is Rheumatic Heart Disease?
Rheumatic heart disease develops as a consequence of rheumatic fever, which occurs after a strep throat or scarlet fever infection. In susceptible individuals, the immune system mistakenly attacks the body’s own tissues — particularly the heart, joints, skin, and nervous system — in an autoimmune reaction.
Over time, repeated or severe attacks of rheumatic fever cause chronic inflammation and scarring of the heart valves, particularly the mitral and aortic valves. These changes can lead to:
Valve stenosis: Narrowing of the valve opening, restricting blood flow.
Valve regurgitation: The valve does not close properly, allowing blood to leak backward.
Heart muscle thickening and enlargement: Due to increased strain on the heart.
When left untreated, these complications can result in heart failure, arrhythmias, stroke, or even sudden death.
Causes and Mechanism
Rheumatic heart disease is caused by an abnormal immune response to Group A Streptococcus (GAS) infection of the throat. The bacteria produce proteins that resemble those found in human tissues. The immune system’s attempt to fight the bacteria can inadvertently target heart tissue, particularly the valves.
The condition progresses in three stages:
Streptococcal throat infection (strep throat).
Rheumatic fever develops two to four weeks later if the infection isn’t treated properly.
Chronic valve damage occurs gradually after repeated inflammation and scarring, leading to rheumatic heart disease.
While the initial infection can be mild or unnoticed, repeated exposure or poor access to healthcare significantly increases the risk of RHD.
Risk Factors
Rheumatic heart disease is most common in low- and middle-income regions where access to antibiotics and healthcare is limited. However, several individual and environmental factors increase the risk:
Untreated or recurrent strep throat infections
History of rheumatic fever
Overcrowded living conditions (which increase bacterial transmission)
Poverty and limited access to medical care
Poor hygiene and sanitation
Genetic predisposition to autoimmune reactions
Children between the ages of 5 and 15 are most at risk for rheumatic fever, but valve damage can persist and worsen into adulthood.
Symptoms of Rheumatic Heart Disease
Symptoms of RHD may take years to appear after an episode of rheumatic fever. They depend on which valves are affected and how severely they are damaged.
Common symptoms include:
Shortness of breath, especially during exertion or while lying down.
Fatigue or weakness, due to reduced heart efficiency.
Swelling (edema) in the legs, ankles, or abdomen.
Chest discomfort or palpitations, caused by arrhythmias.
Fainting or dizziness, due to poor circulation.
Heart murmur, detected by a physician using a stethoscope.
In advanced cases, symptoms of heart failure — such as persistent cough, fluid buildup, or weight gain — may develop.
How Rheumatic Heart Disease Is Diagnosed
Early detection and treatment are critical for preventing complications. Diagnosis involves assessing both the history of streptococcal infection and evidence of heart valve involvement.
1. Medical history and physical examination
Doctors look for a history of rheumatic fever, untreated strep infections, and cardiac symptoms.
A characteristic heart murmur may indicate valve damage.
2. Diagnostic tests
Echocardiogram (ECHO): The most important diagnostic tool. It uses sound waves to visualize valve structure, function, and blood flow.
Electrocardiogram (ECG): Detects arrhythmias and measures heart rhythm.
Chest X-ray: Shows heart enlargement or pulmonary congestion.
Blood tests:
Elevated antistreptolysin O (ASO) titers indicate a recent strep infection.
Elevated inflammatory markers (ESR, CRP) suggest ongoing inflammation.
Throat culture or rapid antigen test: Confirms active Streptococcus infection.
Complications of Rheumatic Heart Disease
Untreated or advanced RHD can lead to serious, potentially life-threatening complications, including:
Heart failure: Due to weakened pumping ability.
Atrial fibrillation (AF): Irregular heartbeat that increases stroke risk.
Infective endocarditis: Infection of damaged heart valves.
Stroke: From clots forming in poorly functioning heart chambers.
Pulmonary hypertension: Increased pressure in the lung arteries due to valve obstruction.
These complications highlight the importance of prevention and early management.
Treatment of Rheumatic Heart Disease
Treatment of RHD focuses on three key objectives:
Eliminating residual streptococcal infection.
Controlling inflammation and preventing recurrences.
Managing heart valve damage and complications.
1. Medical Treatment
a. Antibiotics
Penicillin remains the most effective treatment to eliminate Streptococcus bacteria and prevent recurrence of rheumatic fever.
Long-term secondary prophylaxis with intramuscular benzathine penicillin every 3–4 weeks is recommended for patients with a history of rheumatic fever or RHD, often continued for 10 years or more.
b. Anti-inflammatory Drugs
Aspirin or corticosteroids may be used during the acute phase of rheumatic fever to control inflammation and joint pain.
c. Heart Medications
Diuretics help remove excess fluid in cases of heart failure.
Beta-blockers or ACE inhibitors reduce heart workload.
Anticoagulants (e.g., warfarin) may be prescribed if atrial fibrillation is present to prevent blood clots.
2. Surgical and Interventional Treatments
Severe valve damage may require surgery to repair or replace affected valves.
a. Valve Repair
Surgeons may reshape or reinforce the existing valve to improve function. This is usually preferred in younger patients.
b. Valve Replacement
If the valve is too damaged, it may be replaced with a mechanical or biological (tissue) valve.
Mechanical valves are durable but require lifelong anticoagulant therapy.
Biological valves have limited lifespan but do not require lifelong anticoagulants.
c. Balloon Valvuloplasty
A minimally invasive procedure used for mitral stenosis, where a balloon-tipped catheter widens the narrowed valve opening.
3. Long-Term Management
Rheumatic heart disease requires lifelong medical follow-up. Patients need:
Regular echocardiograms to monitor valve function.
Prophylactic antibiotics before dental or surgical procedures (to prevent infective endocarditis).
Continuous medication adherence to manage symptoms and prevent recurrences.
Healthy lifestyle habits — balanced diet, moderate exercise, and avoidance of smoking and alcohol.
Women with RHD who plan to become pregnant should seek preconception counseling due to increased risk of complications during pregnancy.
Prevention of Rheumatic Heart Disease
RHD is almost entirely preventable with timely detection and treatment of strep throat infections.
Primary prevention:
Prompt diagnosis and treatment of strep throat with antibiotics (usually penicillin or amoxicillin).
Secondary prevention:
Continuous prophylactic antibiotic therapy in individuals with a history of rheumatic fever to prevent recurrence.
Public health measures:
Improved access to healthcare and antibiotics.
Community education about recognizing and treating sore throats.
Regular school screenings in high-risk regions.
Prognosis
With early diagnosis and consistent management, many people with RHD live productive lives. However, without treatment, the disease can lead to progressive valve damage and life-threatening complications. The outcome largely depends on:
The severity of valve involvement.
The success of surgical interventions.
Consistency with preventive antibiotic therapy.
Conclusion
Rheumatic heart disease is a preventable and treatable condition that continues to pose a global health challenge, particularly in developing regions. By recognizing and promptly treating streptococcal throat infections, providing regular follow-up for affected individuals, and ensuring access to antibiotics, the burden of RHD can be significantly reduced.
Education, prevention, and long-term medical care remain the most powerful tools for protecting the heart from the lasting effects of rheumatic fever.
Disclaimer:
This article is intended for informational purposes only and should not be used as a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare professional regarding any questions or concerns about your heart health.