A complication of rheumatic fever. The main site of pathology is on the valves. There may be mitral stenosis, mixed mitral valve disease (both stenosis and incompetence), mitral incompetence, aortic stenosis and incompetence. Dyspnoea, palpitations, heart murmurs depending on the valvular lesion, patients may be asymptomatic and may be discovered to have the lesion during routine examination or during periods of increased demand such as pregnancy or anaemia. Patients may present also with congestive cardiac failure.

Investigations

• Chest X-ray

• ECG (where available).

Management

• Treat underlying complication e.g. heart failure, pulmonary oedema

• Continuous prophylaxis against recurrent rheumatic fever is indicated

• Infective endocarditis prophylaxis is indicated.

Refer If

• All patients with significant heart murmur for initial evaluation

• All patients with increasing cardiac symptoms.

Prophylaxis

Rheumatic fever - All patients with a history of rheumatic fever should be given prophylaxis for recurrences, for life, with:

• Benzathine penicillin 1.2 mega units IM monthly

OR amoxycyllin 125-250 mg PO BD

OR erythromycin 125-250 mg PO BD.

Endocarditis prophylaxis - In addition to rheumatic fever prophylaxis:

• Dental procedures: Amoxycillin 3.0 gm PO 2 hrs before procedure and 1.5 gm PO 6 hours after the initial dose

• If penicillin allergy - Erythromycin 1 gm PO 2 hrs before procedure then half the dose 6 hours after the initial dose

• Lower gastrointestinal and genitourinary procedures: Amoxycillin 2 gm IM 30 minutes before procedure and 6 hrs after the initial dose + gentamicin 1.5 mg/kg IM 30 minutes before procedure and 8 hrs after the initial dose.

Patient Education

• Emphasize need for follow up
• Advise female patients on contraception.

Complications

Congestive cardiac failure, pulmonary oedema, bacterial endocarditis.