Rheumatic Heart Disease

Rheumatic Heart Disease (RHD) is a serious health condition that stems from untreated or inadequately treated streptococcal throat infections, leading to rheumatic fever and eventually causing permanent damage to the heart valves. It continues to pose a significant burden on public health, especially in under-resourced and developing countries where access to timely healthcare is limited.

This condition, which is largely preventable, still affects children and young adults disproportionately, causing lifelong complications and even early death. Increased awareness, early diagnosis, and proper medical care are the keys to preventing its onset and progression. Understanding the journey of RHD helps individuals and communities better combat this persistent threat.

Rheumatic Heart Disease is a long-term damage to one or more of the heart valves caused by an abnormal immune response to Group A Streptococcus (GAS) infection, most often in the form of untreated or poorly treated strep throat or scarlet fever. The immune system, in attempting to fight off the infection, inadvertently attacks healthy tissues of the heart, leading to inflammation and scarring.

RHD most commonly affects the mitral and aortic valves. When these valves become scarred, they either do not open fully (stenosis) or do not close properly (regurgitation), which impairs normal blood flow and puts strain on the heart. Over time, this can lead to complications such as heart failure, arrhythmias, and stroke.

Global Prevalence

Rheumatic Heart Disease is responsible for significant global health challenges. According to the World Heart Federation, around 40 million people are living with RHD, primarily in low- and middle-income countries. It results in over 300,000 deaths each year and remains a leading cause of cardiovascular morbidity among children and young adults worldwide.

RHD is rare in high-income countries due to widespread access to antibiotics and robust public health systems. However, it remains endemic in many regions of sub-Saharan Africa, South Asia, and the Pacific Islands.

Prevalence in India

India holds one of the highest burdens of RHD in the world. It is estimated that more than 2 million people in India suffer from this condition. School-based screening in some regions has found prevalence rates as high as 1 to 5 cases per 1,000 children. The disease is more common in rural and economically disadvantaged communities.

Rheumatic Heart Disease can manifest in several forms depending on the pattern of valve damage:

1. Isolated Mitral Valve Disease: The mitral valve is most frequently affected, usually leading to mitral stenosis or regurgitation.
2. Aortic Valve Involvement: This can occur alone or alongside mitral valve damage, contributing to aortic stenosis or insufficiency.
3. Multivalvular Disease: Simultaneous involvement of multiple valves, leading to more complex clinical management.
4. Congenital-Rheumatic Overlap: In rare cases, congenital heart defects may be exacerbated by superimposed rheumatic damage.

The primary cause of RHD is rheumatic fever, which results from an autoimmune response to a throat infection with Group A Streptococcus bacteria. If not treated with antibiotics, the infection can cause inflammation in the heart, joints, skin, and brain.

Contributing Factors

• Poor access to medical care
• Delayed or incorrect antibiotic treatment of strep throat
• Recurrence of rheumatic fever
• Overcrowded living conditions
• Malnutrition
• Lack of awareness about the symptoms of strep infections
• Socioeconomic disadvantages and health system gaps
   

Symptoms of RHD can develop gradually and may not appear until significant heart valve damage has occurred. Common signs include:

• Persistent fatigue
• Shortness of breath, especially on exertion or when lying down
• Chest pain or tightness
• Swelling in the ankles, feet, or abdomen
• Palpitations or irregular heartbeats
• Fainting or dizziness
• Heart murmur detected during examination

Children with acute rheumatic fever may also experience:

• Painful, swollen joints
• Fever
• Skin rashes
• Nodules under the skin

Uncontrolled body movements (Sydenham’s chorea)
 

Accurate diagnosis of RHD is crucial to prevent disease progression and manage complications. Diagnosis typically involves:

• Medical History and Examination: Including history of sore throats, joint pain, or previous rheumatic fever.
• Echocardiography: The most reliable tool to assess the extent of heart valve damage.
• Electrocardiogram (ECG): Evaluates electrical activity of the heart.
• Chest X-ray: Checks for enlarged heart or fluid in the lungs.
• Blood Tests: Include antistreptolysin O (ASO) titre to confirm prior strep infection and inflammatory markers like CRP and ESR.

Treatment of RHD aims to manage symptoms, prevent further damage, and address any complications that arise. A multi-pronged approach is typically used:

Medical Treatment

• Antibiotic Prophylaxis: Long-term penicillin injections (usually every 3–4 weeks) to prevent recurrence of strep infections. Brand: Fortified procaine penicillin injections)
• Anti-inflammatory Drugs: Such as aspirin or corticosteroids during acute episodes. (Brand: Afdiflam Tablet)
• Cardiac Medications: Including diuretics, beta-blockers, and anticoagulants depending on the severity.
• Management of Heart Failure: With medications like ACE inhibitors or digitalis.

Surgical Intervention

• Valve Repair Surgery: Preferable in young patients as it retains natural valve structure.
• Valve Replacement Surgery: Required in advanced cases, using either mechanical or bioprosthetic valves. Patients with mechanical valves require lifelong anticoagulation therapy.
   

While conventional medical treatments remain the cornerstone of RHD management, alternative therapies may be used to support overall wellness:

• Yoga and Meditation: Help in reducing stress, improving breathing, and enhancing cardiac function.
• Herbal Medicine (Ayurveda): Some herbs like Arjuna and Ashwagandha are believed to support heart health, though clinical evidence is limited.
• Homeopathy: May be used for symptom relief; however, it should not replace standard care.
• Nutritional Therapy: A diet rich in antioxidants, low in salt, and supportive of cardiovascular health.

Always consult a healthcare provider before beginning any alternative treatments.

Individuals with the following risk factors are more prone to developing RHD:

• Children aged 5–15 years
• Repeated streptococcal throat infections
• Poor sanitation and hygiene
• Inadequate healthcare infrastructure
• Crowded living conditions
• Family history of rheumatic fever or RHD
• Malnutrition

Unmanaged or poorly treated RHD can lead to a range of serious complications:

• Heart Failure: Due to chronic pressure on heart chambers from faulty valves.
• Arrhythmias: Such as atrial fibrillation, increasing stroke risk.
• Stroke: Often linked to clots formed due to irregular heartbeats.
• Infective Endocarditis: A dangerous infection of damaged heart valves.
• Pregnancy Complications: Including heart failure and poor fetal outcomes.
• Pulmonary Hypertension: Due to increased pressure in lung arteries.
   

Living with RHD requires a combination of medical adherence, lifestyle adjustments, and emotional resilience:

• Follow Treatment Plans: Take medications consistently and attend regular check-ups.
• Eat a Heart-Healthy Diet: Low in sodium, rich in fruits and vegetables.
• Stay Physically Active: Engage in moderate activities approved by your doctor.
• Avoid Smoking and Alcohol: Both can aggravate heart conditions.
• Manage Stress: Through yoga, meditation, or counselling.
• Watch for Warning Signs: Report any sudden weight gain, fatigue, or palpitations.

• Myth: Only elderly people get RHD.
   Fact: It mostly affects children and young adults in developing regions.
• Myth: A sore throat is never serious.
   Fact: Strep throat, if untreated, can lead to rheumatic fever and RHD.
• Myth: Surgery cures RHD permanently.
   Fact: Surgery manages symptoms but does not prevent recurrence without ongoing prophylaxis.
• Myth: RHD is contagious.
   Fact: The bacterial infection is contagious, not the heart disease.

Consult a healthcare provider if you or your child experiences:

• Recurrent or prolonged sore throat
• Joint pain accompanied by fever
• Unexplained fatigue
• Shortness of breath
• Irregular heartbeats or chest discomfort

Early medical intervention can prevent the onset or worsening of RHD
 

• What type and stage of RHD do I have?
• What treatment options are best for me?
• Will I need surgery, and if so, when?
• How can I prevent future flare-ups?
• Is my condition manageable with lifestyle changes?
• What should I do if I miss a dose of medication?

Support from friends, family, and caregivers is essential:

• Be Patient and Empathetic: Understand the fatigue and limitations they face.
• Assist with Appointments and Medications: Help them keep track of their treatment schedule.
• Encourage Healthy Habits: Join them in eating well, exercising, or quitting smoking.
• Educate Yourself: Knowing more about the condition helps you offer better support.
• Offer Emotional Support: Encourage open conversations about their feelings and struggles.
   

Rheumatic Heart Disease, though preventable, remains a major cause of heart-related morbidity and mortality, especially in low-resource settings. Early detection, consistent antibiotic prophylaxis, and timely medical intervention are essential in controlling its impact.

Through collective efforts involving individuals, healthcare providers, and public health systems, the burden of RHD can be significantly reduced. Raising awareness and improving living conditions will also go a long way in eliminating this preventable condition.