Rheumatic Fever (Acute) and Rheumatic Heart Disease

Common illness among children and young adults.

Primary chronic sequelae is RHD.

Worldwide estimate is over 15 million cases of RHD, with 282,000 new cases and 233,000 deaths annually.

Up to 1% of all school-age children in Africa, Asia, Latin America, and the eastern Mediterranean show signs of the disease.

In ARF with acute cardiac manifestations (including first-degree heart block and pericarditis), medications and equipment for maintaining heart rhythm and function during anesthesia should be available.

An actively febrile pt’s surgery should be delayed unless it is urgent or emergent.

The approach to anesthesia in RHD must be tailored to the pt’s specific physiologic parameters. Control of the pt’s hemodynamic profile to optimize cardiovascular stability will depend on which valves are damaged and the extent of the myocardial compromise, either from RHD or from secondary cardiovascular effects due to chronic valvular disease.

In the presence of valvular disease, prophylactic antibiotics should be given to prevent bacterial endocarditis.

Periop assessment of cardiac status, including direct and indirect effects of chronic valvular disease on cardiac function, must be performed prior to surgery. Pts may be clinically asymptomatic for 20 y after developing RHD owing to compensatory alterations in cardiac structure and function. Knowledge of the cardiac compensatory changes in heart function is essential.

If valvular damage is present, maintain tight control of cardiac rate and rhythm, pulmonary and systemic vascular resistance, and intravascular fluid volume.

If pulm hypertensive crisis occurs, hyperventilate and increase inspired O ₂ to 100%.

ARF is primarily due to a pharyngeal infection with Streptococcus pyogenes or group A beta hemolytic streptococcus, which is a common cause of throat infections in children. If left untreated, the child can develop ARF, which is an inflammatory response occurring 2–3 wk after the initial infection.

RHD is an autoimmune reaction with cardiac tissue, resulting in permanent deformities of heart valves or chordae tendineae.

Scarring leads to valvular stenosis, classically in the mitral valve followed by the aortic valve. However, all cardiac valvular defects can occur.

Joint pain and carditis with valve damage are the major clinical manifestations of ARF. Carditis can occur in up to 80% of people with ARF, leading to mitral or aortic valvular disease. About half of those affected will develop chronic RHD. Death from ARF is not common, but chronic rheumatic heart disease can lead to morbidity from arrhythmias, endocarditis, and stroke.