Rheumatic heart disease

Rheumatic heart disease (RHD) is permanent damage to the heart valves caused by one or more episodes of rheumatic fever — an immune reaction to untreated streptococcal throat infection in childhood. RHD remains a significant public-health problem in India and other low- and middle-income countries, even though it has become rare in high-income countries.

According to the WHO, over 40 million people globally live with RHD, with the highest burden in Sub-Saharan Africa, South Asia, and the Pacific. India is estimated to account for a substantial share of the global burden.

How does it develop?

The path is preventable at several steps:

• A child has a streptococcal throat infection ("strep throat"). Usually presents with sore throat and fever.
• If untreated or inadequately treated, some children develop acute rheumatic fever 2-4 weeks later — with fever, joint pain, rash, and sometimes heart involvement.
• Repeated episodes of rheumatic fever damage the heart valves — most commonly the mitral valve, then the aortic valve.
• Over years, the damage progresses to rheumatic heart disease — heart failure, abnormal rhythms, blood clots, and infection of the valves (endocarditis).

Symptoms

RHD may be silent for years before symptoms appear:

• Breathlessness with exertion or when lying down
• Swelling of feet, ankles, or abdomen
• Palpitations or irregular heartbeat (atrial fibrillation is common)
• Chest pain or discomfort
• Fatigue
• In pregnancy, pre-existing RHD can cause significant complications for mother and baby

Diagnosis

• Clinical examination — heart murmurs from damaged valves
• Echocardiogram — the key test, shows valve damage directly
• ECG
• Chest X-ray
• Blood tests including streptococcal antibody tests during acute rheumatic fever

Treatment

• Penicillin prophylaxis — monthly injections of long-acting penicillin (benzathine penicillin) after rheumatic fever, to prevent further streptococcal infections and further damage. Continued for many years, often lifelong for severe valve disease.
• Medicines for heart failure, arrhythmias, blood thinners for atrial fibrillation or severe valve disease
• Valve surgery or valve replacement — when valve damage is severe. Options include repair, mechanical valves, or biological valves. Balloon valvotomy is a minimally-invasive option for selected mitral valve cases.

Prevention

RHD is entirely preventable if:

• Sore throats in children are assessed promptly, and strep throats are treated with a full course of antibiotics (usually penicillin or amoxicillin)
• After rheumatic fever, long-term penicillin prophylaxis is given consistently
• Echocardiographic screening in high-risk populations can detect early subclinical disease

India has active programmes for RHD awareness and school-based screening, and the disease is a public-health priority.