OVERVIEW

What is rheumatic valvular heart disease in rheumatic heart disease?

Rheumatic valvular heart disease refers to a condition where rheumatic fever affects the heart valves, causing damage. Rheumatic fever was once the most common cause of valvular heart disease in China, with about half of valvular heart disease patients having a history of rheumatic fever.

In recent years, due to social development and improved medical conditions, the incidence of rheumatic valvular heart disease has significantly decreased.

What is the difference between rheumatic heart disease and rheumatic valvular heart disease?

Rheumatic valvular heart disease is a type of rheumatic heart disease. Rheumatic fever can also cause myocarditis or pericarditis, and the coexistence of these three conditions is called pancarditis.

Among them, valvular heart disease is the most common, so the term "rheumatic heart disease" often refers to rheumatic valvular heart disease.

What is the function of heart valves?

The main function of the heart is to pump fresh blood and recycle used blood, consisting of four chambers and several major pathways. Heart valves act as critical gateways, determining the flow of blood, similar to the doors of a room or traffic lights at highway ramps.

Therefore, when valves become narrowed or fail to close properly, blood flow is obstructed, affecting heart function.

SYMPTOMS

What are the types of rheumatic heart disease?

• It is mainly classified based on the affected valves, including the mitral valve, aortic valve, tricuspid valve, and pulmonary valve. Symptoms may vary slightly depending on the location.
• Each can be further categorized into stenosis and regurgitation. Stenosis means the blood flow passage is too narrow, while regurgitation causes blood backflow, both reducing blood output and increasing cardiac workload.

The mitral valve is most commonly affected, followed by the aortic valve, while the tricuspid and pulmonary valves are rarely involved.

What are the symptoms of rheumatic heart disease?

Early stages may show no obvious symptoms, often presenting as mild shortness of breath or fatigue after activity. As the disease progresses, symptoms like an enlarged heart, palpitations, and chest tightness may appear. In advanced stages, heart failure symptoms may occur, including severe dyspnea, inability to lie flat at night, coughing up large amounts of pink frothy sputum, and ultimately, death from heart failure.

The damage is primarily manifested through various complications.

What diseases can rheumatic heart disease cause?

• Arrhythmia: Early stages may show atrial premature beats, progressing to atrial flutter and atrial fibrillation, eventually becoming chronic persistent atrial fibrillation. Atrial fibrillation is a common complication of rheumatic heart disease.
• Acute pulmonary edema: One of the more severe complications, presenting as sudden severe dyspnea, inability to lie flat, and coughing up pink frothy sputum. Without prompt treatment, it can be fatal.
• Thromboembolism: Atrial fibrillation is a major cause of thrombus formation, with 20% of patients experiencing thromboembolism.
• Congestive heart failure: About 50% of rheumatic heart disease patients are prone to congestive heart failure due to long-term structural damage from rheumatic inflammation, reducing the heart's pumping ability.
• Subacute infective endocarditis and pulmonary infections.

Why does heart failure occur in the late stages of rheumatic heart disease?

Rheumatic fever inflammation damages the heart valves, causing stenosis or regurgitation.

Valves act as critical gateways between the heart's chambers and major vessels. Like a door, malfunction (regurgitation or stenosis) impairs the heart's ability to pump blood effectively, preventing it from supplying fresh blood or fully recycling used blood.

To compensate, the heart undergoes structural changes. During exertion or infection, increased demand further strains the heart.

Initially, the heart compensates by increasing heart rate. However, as the disease progresses, pumping function deteriorates, leading to heart failure. Symptoms like dyspnea arise, and due to the interconnected cardiopulmonary system, hemoptysis or pulmonary edema often occur.

CAUSES

Rheumatic heart disease is caused by rheumatic fever. What causes rheumatic fever?

Rheumatic fever is a series of acute or chronic non-suppurative inflammatory conditions of the systemic connective tissues triggered by infection with group A beta-hemolytic streptococci, primarily affecting the joints and heart. Rheumatic fever usually occurs one week to several weeks after an upper respiratory streptococcal infection. While joint damage caused by rheumatic fever can resolve on its own, heart damage is irreversible.

Rheumatic heart disease is caused by rheumatic fever. Who is more susceptible to rheumatic fever?

The disease can occur at any age but is rare in children under 3 years old. It is most common in children and adolescents aged 6–15, with roughly equal incidence between males and females.

What season is rheumatic fever, the cause of rheumatic heart disease, most likely to occur?

It can occur year-round but is more prevalent in the cold and rainy winter and spring seasons. Cold and damp conditions are significant contributing factors. Additionally, crowded living conditions, malnutrition, and poor medical care can promote the spread and proliferation of streptococci, leading to outbreaks of the disease.

What are the causes of rheumatic heart disease?

The pathogenesis is complex, primarily involving an autoimmune response triggered by group A beta-hemolytic streptococcal infection. In simple terms, after infection, the body mistakenly attacks its own organs, causing damage. Repeated episodes lead to permanent scarring of the heart valves, ultimately resulting in structural changes such as stenosis or regurgitation.

Is rheumatic heart disease hereditary?

Families with a history of rheumatic fever have a higher incidence of the disease compared to those without such history. However, there is currently no direct evidence proving it is a genetic disorder.

DIAGNOSIS

What tests are done for rheumatic heart disease?

In addition to routine tests, blood tests of RHD patients may show elevated anti-streptolysin O (ASO), C-reactive protein, and erythrocyte sedimentation rate (ESR). For assessing structural heart changes, echocardiography, chest X-ray, and electrocardiogram are required.

TREATMENT

How to treat rheumatic heart disease?

The general treatment principles include: early diagnosis, reasonable treatment, and preventing disease progression from causing irreversible heart damage.

• General treatment: Avoid strenuous physical activity and acute infections as much as possible. Patients with congestive heart failure should also moderately restrict salt and fluid intake.
• Anti-rheumatic treatment: To prevent rheumatic fever recurrence, benzathine penicillin is the first choice, recommended for long-term or even lifelong use.
• Managing complications: Sedation, diuresis, vasodilation of small arteries, ventricular rate control, and anticoagulation to prevent thrombosis.
• Surgical treatment: Valve repair or valvuloplasty, and artificial valve replacement.

When do rheumatic heart disease patients require anticoagulation therapy?

The main purpose of anticoagulation is to prevent thrombosis and thromboembolism. Patients with persistent or permanent atrial fibrillation, a history of embolism, or left atrial thrombosis detected by echocardiography should receive long-term warfarin anticoagulation therapy if there are no clear contraindications.

How to treat heart failure in rheumatic heart disease patients?

• Restrict sodium intake.
• Rest and oxygen therapy.
• Diuresis: Helps rapidly eliminate excess fluid from the body, reducing cardiac workload.
• Vasodilation (nitrate medications) to reduce vascular resistance and ease the heart's burden.
• Delaying cardiac structural changes: Medications such as ACE inhibitors and beta-blockers (e.g., metoprolol) significantly improve prognosis.

What are the surgical options for rheumatic heart disease?

Surgical approaches vary slightly depending on the affected valve and whether stenosis or regurgitation is present. The most common procedure is artificial valve replacement. For valve stenosis, valvuloplasty or balloon dilation may be performed, but if these are not feasible, artificial valve replacement is still used.

What types of artificial heart valves are used in rheumatic heart disease treatment?

Artificial heart valves are divided into two main categories based on material: mechanical valves, made entirely of synthetic materials, and biological valves, made wholly or partly from biological tissue.

• Mechanical heart valves have superior durability and no risk of calcification, but patients require lifelong anticoagulation post-surgery. Without strict anticoagulation, the risk of thrombosis is high, and there is also a danger of cerebral hemorrhage due to anticoagulant use. Due to their design, mechanical valves may cause backflow when closing, leading to progressive anemia from hemolysis.
• Patients with biological heart valves typically need anticoagulation for six months to a year post-surgery, though the duration depends on individual conditions. Biological valves have a shorter lifespan than mechanical valves due to calcification issues.

What is the prognosis for rheumatic heart disease treatment?

It mainly depends on the severity of heart damage. Patients with significant clinical symptoms, such as atrial fibrillation, chronic heart failure, cardiac enlargement, or a history of embolism, have a poorer prognosis. However, active surgical treatment can improve quality of life and survival rates.

DIET & LIFESTYLE

What are the dietary requirements for patients with rheumatic heart disease?

Patients with valvular heart disease should have a balanced diet combining whole grains, lean meats, and vegetables, avoiding excessive high-fat foods to prevent interference with anticoagulation effects or increased cardiac burden. Nutrition and variety should be increased to ensure adequate protein and vitamin intake, and overly salty foods should be avoided.

What should patients with rheumatic heart disease pay attention to in daily life?

• When patients exhibit obvious symptoms of cardiac insufficiency or are in an active phase of rheumatic fever, they must rest absolutely in bed, with all daily activities assisted by family members, and seek medical attention promptly.
• When symptoms are mild, patients may engage in light work or exercise to improve endurance and cardiopulmonary function, preferably aerobic activities such as walking, swimming, or cycling.
• Avoid heavy physical labor to prevent additional strain on the heart.
• Regular hospital visits and follow-ups are necessary to monitor changes in cardiac function and structure, allowing timely adjustments to medications and treatment plans.

PREVENTION

How to prevent rheumatic heart disease?

With improvements in lifestyle and living conditions, the incidence rate has significantly decreased. However, for confirmed streptococcal infections, immediate antibiotic treatment is required. For patients with rheumatic valvular heart disease, continuous injections of benzathine penicillin may be necessary to prevent recurrence.