What are the Treatments for Rheumatic Diseases that cause Heart Damage, and when are they Needed?

Untreated strep throat can be complicated by rheumatic fever, an inflammatory disease which affects the joints and can sometimes damage the heart. Most cases of this disease occur in childhood, while approximately 20% of cases occur in adults (Chin).

There are several options for treatments for rheumatic diseases involving the heart. The type of treatment necessary depends on the stage of the disease. Antibiotics are typically used to prevent recurrences of rheumatic fever that might cause further heart damage. If damage to the heart is severe enough, surgery might be required.

Medication to treat Rheumatic Disease

Whether or not the heart has already been damaged, one of the most important aspects of treating rheumatic fever is preventing further damage. In addition, any damage that has already been done must also be treated. Whenever possible, these aims are achieved with medication.

• Oral penicillin is the drug of choice for treating the infection that causes strep throat and rheumatic fever. Intramuscular penicillin injections might be used in some cases. If the individual is allergic to penicillin, erythromycin is used.

• The acute inflammation that develops in rheumatic fever is treated with moderately high doses of aspirin. Steroids are used when stronger medication is needed. Anti-inflammatory treatment always includes steroids in any case where the heart is affected.

• If the patient is affected by congestive heart failure, additional medication might include diuretics and digoxin.

Preventative therapy with antibiotics can continue for a lengthy period of time, typically several years or longer. This is important to minimize heart damage. Even when no damage has been done to the heart, preventative antibiotics might be administered for up to five years, or until a young patient reaches the age of 21. In cases where the heart has been damaged, antibiotics might be administered for at least ten years.

In addition, preventative antibiotics are required before dental and surgical procedures. This is necessary due to the risk of bacterial endocarditis. This inflammation affects the heart valves, and can therefore exacerbate any existing heart damage.

Surgical Treatments and Procedures for Rheumatic Diseases

Forty percent of children with acute rheumatic fever go on to develop a heart condition called mitral valve stenosis during adulthood. In most cases this develops due to the formation of scar tissue on the heart valves, which causes the valves to narrow and function less efficiently.

While medications can reduce heart strain and might ease symptoms, they cannot repair the stenosis. There are two options for heart valve repair: balloon valvuloplasty, and mitral valve surgery.

Balloon Valvuloplasty

Balloon valvuloplasty is a non-surgical procedure similar to a balloon angioplasty for widening narrow arteries. In a balloon valvuloplasty, a catheter fitted with a “balloon” tip is inserted into a groin or arm vein and feed through the body’s arterial system until it reaches the heart. Once the catheter tip is in place at the defective heart valve the balloon is inflated to stretch the valve. The stretching helps to improve the flow of blood through the valve and relive symptoms of mitral valve stenosis.

This procedure is not appropriate for all people with rheumatic heart disease, however, and many people who undergo this procedure must have it repeated within approximately ten years to re-stretch the valve.

Mitral Valve Surgery

Mitral valve surgery might involve a valvuloplasty, in which the mitral valve is repaired, or a mitral valve replacement, in which the defective valve is replaced with a new synthetic valve. In most cases, mitral valve replacement is preferred over valvuloplasty.

People who receive a replacement mitral valve can choose between a metal valve or a tissue valve. The metal valve is durable and generally does not need to be replaced; however a patient who receives a metal valve must take blood thinning medication to prevent the formation of blood clots near the valve. The alternative is a tissue valve, which can come from a cow, pig, or human donor. These valves do not increase the risk of blood clots, but are likely to require replacement.

Other Aspects of Treatment

In addition to medication and surgery, certain other measures might be used to treat rheumatic fever or rheumatic heart disease.

In cases of rheumatic fever where the heart is affected, complete bed rest is often required. This is because some patients are affected by congestive heart disease during the acute inflammation phase. This disease does not always persist after the acute phase has passed, and bed rest is necessary to reduce strain on the heart and help the patient recover.

When the heart is affected in this way, following a low-fluid and low-sodium diet is also important to reduce fluid buildup in the lungs and the rest of the body. Excess fluid strains the heart, and fluid buildup is more likely to occur in congestive heart disease. Keeping fluid and salt intake low helps reduce fluid buildup and heart strain.

References

American Heart Association: Rheumatic Heart Disease/Rheumatic Fever

Seattle Children’s Hospital Research Foundation: Rheumatic Heart Disease

Thomas K Chin, MD, for eMedicine: Rheumatic Heart Disease

University of California San Francisco Benioff Children’s Hospital: Rheumatic Heart Disease