Rheumatic heart disease CVS 4 Hisham Alkhalidi

Rheumatic fever (RF) Acute Immunologically mediated Multisystem inflammatory disease Occurs few weeks after an episode of: group A β-hemolytic streptococcal pharyngitis

RF Usually affects children 5-15 years 20% of first attacks occur in adults In economically depressed urban areas or developing countries, RF and RHD remain important public health problems

Acute rheumatic mitral valvulitis superimposed on chronic rheumatic heart disease.

Chronic RHD Mitral stenosis with diffuse fibrous thickening and distortion of the valve leaflets, commissural fusion (arrows) Thickening and shortening of the chordae tendineae

Chronic RHD Organization of the acute inflammation and subsequent scarring Aschoff bodies are replaced by fibrous scar, so diagnostic forms of these lesions are rarely seen in chronic RHD The major functional consequence of RHD is: Valvular stenosis and regurgitation

MITRAL VALVE IS THE COMMONEST VALVE AFFECTED MAT 70 % M 25 % M+A

Diagnosis of acute RHD serologic evidence of a previous streptococcal infection + two or more of the following Jones criteria: (1) carditis, (2) migratory polyarthritis of the large joints, (3) subcutaneous nodules, (4) erythema marginatum of the skin, and (5) Sydenham chorea, a neurologic disorder with involuntary purposeless, rapid movements One of the Jones criteria manifestations and two minor manifestations (nonspecific signs and symptoms that include fever, arthralgia, or elevated blood levels of acute-phase reactants)

After an initial attack there is increased vulnerability to disease reactivation with subsequent pharyngeal infections. Carditis is likely to worsen with each recurrence, and damage is cumulative

Chronic rheumatic heart disease More likely to occur when the first attack: – In early childhood – Sever – Recurrence The long-term prognosis is highly variable Surgical repair or replacement of diseased valves has greatly improved the outlook for patients with RHD

Chronic RHD The signs and symptoms of valvular disease depend on which valve(s) are involved Mitral stenosis is the most common manifestation Cardiac murmurs Cardiac hypertrophy and dilation CHF Arrhythmias (atrial fibrillation in the setting of mitral stenosis) Thromboembolic complications Increased risk of subsequent infective endocarditis.