Rheumatic heart disease

In Germany, rheumatic heart disease has become a rare illness over recent decades.

Today, the disease mostly occurs in countries with a poor level of medical care and in people who have only limited access to medical care.

In rheumatic heart disease, there is often a narrowing of the heart valve between the left atrium (upper chamber) and left ventricle (lower chamber) of the heart and between the left ventricle and the aorta – the main artery in the body. Sometimes, these valves are no longer able to close fully.

As a result, the heart muscle has to work harder to pump enough blood around the body. This initially goes unnoticed but, after several years, the heart muscle loses power and heart failure occurs, where the heart can no longer pump blood as well as normal.

Other symptoms are cardiac arrhythmias (irregular heartbeat) and inflammation of the endocardium. In rarer cases, blood clots form in the heart, which can reach the brain via the bloodstream and cause a stroke.

The most important measure that can be taken to prevent rheumatic heart disease is to consistently treat streptococcal infections with antibiotics designed to fight this type of bacteria.

If streptococcal bacteria are identified as being responsible for a throat infection, it is important for the prescribed antibiotics to be taken as directed by the doctor. This treatment normally prevents the occurrence of rheumatic fever and the subsequent development of rheumatic heart disease.

In a physical examination, the doctor uses a stethoscope to listen to the heart. Abnormal heart sounds are typically heard in patients with rheumatic heart disease. These occur as the blood flows through the altered valves of the heart. An ultrasound scan of the heart (echocardiogram) serves to detect changes in the heart valves or heart muscle.

If the patient has previously had symptoms of rheumatic fever, this is another indicator of rheumatic heart disease.

If the heart muscle is also affected, this can be detected in a blood sample. In the past, a tissue sample was taken for the purpose of detecting heart muscle inflammation (myocarditis). This is often associated with side effects. For this reason, doctors are increasingly using imaging techniques such as magnetic resonance tomography (MRT) instead.

Rheumatic heart disease is a long-term complication of an infection with streptococcal bacteria. These bacteria cause throat infections, which are often painful.

Streptococci have properties similar to the body’s own cells. Some people’s immune systems produce antibodies that initially attack the bacteria. However, within a period of two weeks, these antibodies can also begin to attack the body’s own cells.

This causes inflammation, known as rheumatic fever. The inflammation can affect the heart muscles, as well as the heart’s innermost lining (endocardium) and outermost lining (epicardium). However, the heart valves are most affected. If these become damaged to the extent that they can no longer close properly, the person will develop heart failure (cardiac insufficiency) over time. Sudden heart failure is also possible.

In many cases, the symptoms of rheumatic heart disease do not become apparent until 10 to 20 years after the person falls ill with rheumatic fever.

The following symptoms then occur:

• noticeable heart palpitations
• fatigue, tiredness
• breathing difficulties, shortness of breath
• chest pain
• fainting
• swelling in the legs, fluid retention

The patient’s medical history will also always include episodes of rheumatic fever, inflammation of the heart muscle, joint pain, neurological symptoms and skin rashes.

Rheumatic heart disease is a late complication of rheumatic fever. Rheumatic fever itself is caused by bacteria belonging to the group A Streptococcus. The first sign of this infection is a sore throat, which may be accompanied by a scarlet skin rash.

The body’s immune system produces antibodies to fight the bacteria. These attack the structure of the bacteria, which have certain properties that are very similar to the body’s own cells. For this reason, an excessive immune response may occur, where the antibodies also attack and damage the body’s own tissue. This can result in rheumatic fever, with a high temperature, weakness, joint pain and chest pains.

The antibodies attack cells in the heart in particular. This results in inflammation of the heart’s innermost layer (endocarditis), outermost layer and of the heart muscles. The valves in the heart may also be damaged. This damage is not repaired over time and, in the long term, causes rheumatic heart disease.

In treating rheumatic heart disease, the goal is to contain the disease so that it doesn’t progress to a more advanced stage. This is done using antibiotics on a preventive basis over several years. This type of treatment can prevent the body’s immune system from being re-activated by streptococcal bacteria and attacking the heart again.

If the heart valves have already been damaged, they need to be repaired or replaced with artificial valves. For this purpose, surgeons perform open-heart surgery or use a minimally invasive procedure with a catheter – a flexible plastic tube that is inserted into an incision in the groin and guided through a blood vessel until it reaches the heart. Different procedures are used depending on which heart valves are affected.

If the heart muscle is inflamed, doctors prescribe medication to support the functioning of the heart and regulate the heart’s rhythm. In this case, limiting physical activity is an important part of treatment.