DR.C.R.RAWAT

M.D,FACC,FESC,FCSI,FISC

CONSULTANT CARDIOLOGIST

World scenario of rheumatic heart disease

Area Prevalence Per 1000 United States 0.6Japan 0.7India 6.0-11.0Asia (other) 0.4-21.0Africa 0.3-15.0South America 1.0-17.0

RF is the most common cause of

heart disease in 5-30 yr age group

RHD REMAINS A MAJOR HEALTH CONCERN AROUND THE GLOBE

15.6 million people have RHD in the world .2,82,000 cases are added each year.2,33,000 deaths occur each year.

WORLD RHD BURDEN

IN INDIA ,RHEUMATIC FEVER IS ENDEMIC AND REMAINS ONE OF THE MAJOR CAUSES OF CV DISEASE ACCOUNTING FOR 25%-45 % OF ACQUIRED HEART DISEASE. INDIA IS IN A PHASE OF EPIDEMIOLOGICAL TRANSITION ,ON ONE HAND THERE IS BURDEN OF RHD AND ON OTHER HAND GOVERNMENT RESOURCES ARE SCARSE .

RHD in IndiaRHD in India

Prevalence: 5/1000 population of 5-15 age group

1 million RHD cases in India

Hospital admissions due to RHD is 20-30% of CVD

Acute rheumatic fever (ARF) is a systemic disease of childhood

It is a delayed non-suppurative sequelae to URTI with group A BETA-hemolytic streptococci

It is a diffuse inflammatory disease of connective tissue,primarily involving heart,blood vessels,joints, subcut.tissue and CNS

Epidemiological Factors

Agent

Age: 5-15 yrs(most susceptible)

Sex: both

Environmental factors over crowding, poor sanitation, poverty

Incidence more during winter & early spring

Host Factors

Prevalance of rheumatic fever in different age groups

IMMUNE SYSTEM RESPONSE

Flitting & fleeting migratory polyarthritis, involving major joints

Commonly involved joints-knee,ankle,elbow & wrist

Occur in 80%,involved joints are exquisitely tender

In children below 5 yrs:It is mild but carditis is more prominent

Arthritis does not progress to chronic disease

1.Arthritis

Manifest as pancarditis(endocarditis, myocarditis and pericarditis),occur in 50% of cases

Carditis is the only manifestation of rheumatic fever that leaves a sequelae & permanent damage to the organ

Valvulitis occur in acute phase

Chronic phase- fibrosis,calcification & stenosis of heart valves(fishmouth valves)

2.Carditis

PREVALENCE OF RHD/RF AND PATTERN OF VALVE INVOLVEMENT IN THE COMMUNITY

POPULATION SCREENED 1882MALE 909FEMALE 973RF/RHD 11 (5.8/1000)FEMALE 01(1.1/1000)MEAN AGE OF RF/RHD PATIENTS 30.36 YRS

LESIONSTOTAL 11NO CARDITIS 01ISOLATED MS 02ISOLATED MR 01MS WITH MR 03MS WITH AR 01MR WITH AS 01ISLOATED AR 01POST MVR 01POST PTMC 01 KNOWN RHD 07

MITRAL VALVE STENOSIS AS SEEN IN RHEUMATIC HEART DISEASE

Rheumatic heart disease. Abnormal mitral valve. Thick, fused chordae

Occur in 5-10% of cases

Mainly in girls of 1-15 yrs age

Clinically manifest as-clumsiness, deterioration of handwriting, emotional lability or grimacing of face

Clinical signs- pronator sign, jack in the box sign , milking sign of hands

3.Sydenham Chorea

Occur in <5%.

Unique,transient,serpiginous lesions of 1-2 inches in size

Pale center with red irregular margin

More on trunks & limbs & non-itchy

Worsens with application of heat

Often associated with chronic carditis

4.Erythema Marginatum

Occur in 10%

Painless,pea-sized,palpable nodules

Mainly over extensor surfaces of joints,spine,scapulae & scalp

Associated with strong seropositivity

Always associated with severe carditis

5.Subcutaneous nodules

Other features (Minor features)

Fever(mild)

Polyarthralgia

Pallor

Anorexia

Loss of weight

Onset and progression of different

High ESRAnemia, leucocytosisElevated C-reactive protienASO titre >200 Todd units.(Peak value attained at 3 weeks,then comes down to normal by 6 weeks) Anti-DNAse B test Throat culture-GABH streptococci

LABORATORY DIAGNOSIS

# RHEUMATIC FEVER IS MAINLY A CLINICAL DIAGNOSIS #.No single diagnostic sign or specific laboratory test available for diagnosis #.Diagnosis based on MODIFIED JONES CRITERIA

If the patient has Chorea alone then it is difficult to diagnose rheumatic fever

Insidious or late-onset carditis with no other explanation

PITFALLS IN JONES CRITERIA

1. DIFFICULT TO DIAGNOSE ARF WHEN CARDITIS IS ONLY MANIFESTATION SPECIALLY IN RECCURENCE

2. SUBCLINICAL CARDITIS IS DIFFICULT TO DETECT CLINICALLY

3. CLINICAL CARDITIS IS PRESENT BUT SUPPORTIVE MINOR CRITERIA ARE NOT FULFILLED

4. WHEN PREVIOUS CARDIAC STATUS IS UNKNOWN IT IS DIFFICULT TO SAY WHETHER THE FINDINGS ARE USUALLY ACUTE CARDITIS OR RECURRENCE OR IT IS OLD RHD.

5. IN CASES OF POLYARTHRALGIA IF NOT EVALUATED FOR ARF THEY WOULD GO UNDIAGNOSED

Developing role of ECHOCARDIOGRAPHY IN DIAGNOSIS AND MANAGEMENT OF RHEUMATIC FEVER

GOALS OF ECHO INTERROGATION

1. IT CAN HELP IN PRECISE AND EARLY DIAGNOSIS OF ARF .

2. IT CAN PREVENT OVER DIAGNOSIS OF CARDITIS DEPENDING ON THE TRADITIONAL CLINICAL AUSCULTATORY FINDINGS

3. REGULAR CHECK UP WITH NON INVASIVE ECHO CAN HELP TO EVALUATE THE STATUS OF RHD AND DECIDE FOR ELECTIVE BALOON VALVULOPLASTY FOR MITRAL STENOSIS AND TIMELY DECISION FOR VALVE REPAIR /REPLACEMENT .THIS CAN REDUCE THE MORBIDITY AND MORTALITY ,BEFORE THE PATIENT DEVELOPS CHF .

ECHOCARDIOGRAPHIC INVESTIGATIONS

M-MODE INTERROGATION

.DIMENSIONS OF LEFT ATRIUM ,AORTA AND THEIR RATIO

.LEFT VENTRICULAR DIMENSION IN DIASTOLE AND SYSTOLE.

CROSS-SECTIONAL INTERROGATION IN LONG AXIS ,FOUR CHAMBER ,FIVE CHAMBER AND SHORT AXIS

.THICKNESS OF VALVES WITH <3 MM TAKEN AS NORMAL AND >4 MM AS THICKENED

.BEADED APPEARANCE ,ESPECIALLY MITRAL ,TRICUSPID AND AORTIC VALVESPROLAPSE OF MITRAL VALVE ,PARTICULARLY AORTIC LEAFLET.DECREASED OR INCREASED MOBILITY OF VALVES.HYPERECHOGENICITY OF THE THICKENED SUBMITRAL APPARATUS.CHORDAL TEARS TO MITRAL LEAFLETS .PERICARDIAL EFFUSIONEND DIASTOLIC VOLUME END SYSTOLIC VOLUME AND EJECTION FRACTION

COLOUR DOPPLER INTERROGATION

.ESTABLISHMENT OF MITRAL ,AORTIC AND TRICUSPID REGURGITATION

.DIFFERENTIATION OF PHYSIO AND PATHO REGURGITATION

INCIDENCE OF ECHO FEATURES IN RF

MITRAL THICKNESS >4MM 93.62%

MR GRADE 1-2 83.69%

MVP 56.74%

RH NODULES 26.95%

AR 21.99%

TR 21.99%

PANCARDITIS 9.22%

PERI.EFFUSION 9.22%

CHORDAL TEAR 2.84%

VIJAYA’S ECHO CRITERIA

ECHO - FEATURE SCORE

MV AND AV THICKNESS >=4MM 2

INCREASE ECHO GEN OF SUB MITRAL STR. 2

RHEUMATIC NODULES BEADED APPEARANCE 2

MVP /AVP /TVP 2

MR/PR/AR 2

REDUCED MOBILITY OF VALVES 2

CHORDAL TEAR 2

PERICARDIAL EFFUSION 2

TOTAL SCORE 16

SCORE OF >=6 IS DIAGNOSTIC FOR RHEUMATIC CARDITIS

ROLE OF ECHO IN MANAGEMENT OF ARF IN FUTURE

THE ECHOCARDIOGRAM IS SIMPLE ,NON-INVASIVE,REPRODUCABLE TOOL FOR EARLY AND PRECISE DIAGNOSIS OF CARDITIS IN ARF .

THERE IS A PROPOSAL OF INCLUDING VIJAYA’S ECHO CRITERIA OF CARDITIS AS MAJOR CRITERIA INSTEAD OF ERYTHEMA MARGIRATUM WHICH IS IRRELEVANT ,WHENEVER THERE IS A REVISION OF JONE’S CRITERIA

A, Parasternal long-axis view showing thickening of the mitral valve leaflets. AML, anterior mitral leaflet; LA, left atrium; LV, left ventricle; RV, right ventricle; PML, posterior mitral leaflet. B, Parasternal short-axis view showing the left ventricle and mitral valve in cross-section. Note fine focal nodularity along the edges of the mitral valve (arrows) suggesting verrucae. C, Electrocardiogram (lead II) with prolonged PR interval (160 ms).

Juvenile rheumatiod arthritis

Septic arthritis

Sickle-cell arthropathy

Kawasaki disease

Myocarditis

Scarlet fever

Leukemia

Prevention and control

• To prevent the first attack of RF,by detection and treatment of streptococcal throat inf.

• Many inf are inapparent or undiagnosed

• High risk approach: Surveillance for streptococcal pharyngitis among school children

Primary prevention

Sore throat should be swabbed and cultured

If strepto.— Give Penicillin(If culture is not possible a sore throat can be treated with Benzathine Benzyl Penicillin)

Dose: One IM inj.,1.2 miilion units(adults),0.6 million units(children)

Or Oral Penicillin G/Penicillin V for 10 days

Erythromycin (In case of allergy to Penicillin)

Primary prevention contd…

Secondary Prevention

Other measures in Secondary Prevention

Surveys to know the prevalence of RHD among school children

Every 5 years in 6-14 years age group

Rheumatic fever can recur whenever the individual experience new GABH streptococcal infection,If not on prophylactic medicines

Good prognosis for older age group & if no carditis during the initial attack

Bad prognosis for younger children & those with carditis with valvar lesions

REMEMBER TOGETHER WE CAN FIGHT RHEUMATIC

FEVER AND RHD….WE CAN HEAL THE FUTURE OF OUR NATION AND THE WORLD FOR SURE BY SPREADING AWARENESS AND TIMELY ACTION IN TREATING THE

PATIENTS .

ITS TIME TO ACT….

上級醫師防止疾病醫生治療病前明顯

對下醫生治療完全成熟的病黃 DEE ， HAI-CHING在公元前

2000年（第一屆中國醫療文本