Chronic rheumatic heart diseases

Chronic Rheumatic Heart Disease (CRHD) is a long-term condition that results from rheumatic fever, an inflammatory disease that can affect many parts of the body, including the heart. This condition primarily affects the heart valves, leading to their damage or malfunction. It is a significant cause of morbidity and mortality in many parts of the world, particularly in developing countries where rheumatic fever is more prevalent due to limited access to healthcare and prophylaxis.

Etiology and Pathogenesis

CRHD originates from an episode or recurrent episodes of rheumatic fever, an autoimmune reaction that follows a pharyngeal infection with Streptococcus pyogenes, or group A streptococcus. The body's immune response to the infection mistakenly attacks its own tissues, particularly the heart, joints, skin, and brain. The heart valve damage that characterizes CRHD is primarily due to the inflammation of the endocardium, a condition known as valvulitis. Over time, this leads to scarring and deformation of the heart valves, most commonly the mitral valve and the aortic valve, impairing their function.

Clinical Features

The clinical manifestations of CRHD vary depending on the severity and the valves involved. Common symptoms include shortness of breath, fatigue, chest pain, palpitations, and swelling of the legs and abdomen due to heart failure. Patients may also exhibit signs of valve dysfunction, such as a heart murmur. Advanced cases can lead to severe complications, including atrial fibrillation, stroke, and infective endocarditis.

Diagnosis

Diagnosis of CRHD involves a combination of clinical evaluation, echocardiography, and laboratory tests. The Jones criteria, revised periodically, are used to diagnose rheumatic fever and suggest a potential progression to CRHD. Echocardiography is crucial for assessing valve damage and dysfunction, providing detailed images of the valve anatomy and function.

Treatment

The treatment of CRHD focuses on managing symptoms, preventing progression of valve damage, and addressing complications. This may include medication to manage heart failure symptoms, such as diuretics, beta-blockers, and ACE inhibitors. In cases of significant valve damage, surgical interventions such as valve repair or replacement may be necessary. Secondary prevention of rheumatic fever through continuous or intermittent antibiotics, typically penicillin, is crucial to prevent further damage.

Prevention

Prevention of CRHD is primarily through the prevention and prompt treatment of streptococcal pharyngitis and the prevention of recurrent episodes of rheumatic fever. This includes the use of antibiotics for those with a previous episode of rheumatic fever and improved public health measures to reduce the transmission of Streptococcus pyogenes.

Epidemiology

CRHD remains a significant health issue in many low- and middle-income countries, where access to healthcare and antibiotic treatment is limited. It is less common in high-income countries, where rheumatic fever has become rare due to improved living conditions and access to medical care.

Conclusion

Chronic Rheumatic Heart Disease is a preventable yet still prevalent condition in many parts of the world, leading to significant morbidity and mortality. Continued efforts in public health, access to healthcare, and education are essential to reduce the incidence of this disease.