Treatment of ARF and Rheumatic Carditis
Acute Rheumatic Fever (ARF) and Carditis Management
Supportive Care
- Bed rest recommended.
- Prolonged bed rest (>2-3 weeks) reserved for clinically apparent carditis with heart failure.
- Provide quiet room rest for chorea management.
Antimicrobial Therapy (Primary Prevention)
- Eradicates streptococcal infection upon ARF diagnosis.
- Single injection of benzathine penicillin.
- Alternative: Oral Penicillin V (250 mg four times daily for 10 days).
- Azithromycin utilized for penicillin-allergic patients.
Anti-Inflammatory / Suppressive Therapy
- Treatment duration typically 12 weeks.
- Aspirin: 90-120 mg/kg/day (divided in 4 doses) for 10 weeks, tapered over final 2 weeks. Joint manifestations respond within days. Proton pump inhibitors co-prescribed to avoid gastrointestinal side effects. Naproxen is a viable alternative.
- Corticosteroids: Prednisolone (2 mg/kg daily; max 60 mg) for 3 weeks, tapered gradually over 9 weeks.
- Therapy Selection:
- Carditis with congestive heart failure: Steroids indicated.
- Carditis without congestive heart failure: Steroids or aspirin (steroids often preferred).
- No carditis: Aspirin preferred.
Chorea Management
- Self-limiting disease course.
- Does not respond well to anti-inflammatory agents or steroids.
- Effective medications: Pimozide, haloperidol, diazepam, carbamazepine.
Secondary Prophylaxis
- Prevents recurrent ARF episodes and RHD progression.
- Regimen: Long-acting benzathine penicillin (1.2 million units IM every 3-4 weeks; 600,000 units if <30 kg) or Oral Penicillin V 250 mg twice daily.
| Disease Status | Recommended Duration of Secondary Prophylaxis |
|---|---|
| ARF without carditis | 5 years after last episode or until age 21 (whichever is longer). |
| ARF with carditis (no residual heart disease) | 10 years after last ARF episode or until age 21-25 (whichever is longer). |
| ARF with carditis and residual heart disease / post-valve surgery | Lifelong prophylaxis or at least until age 40. |
Management of Specific Valvular Lesions
| Lesion | Medical Management | Interventional / Surgical Management |
|---|---|---|
| Mitral Regurgitation (MR) | Digitalis, diuretics for symptom relief. ACE inhibitors/ARBs/Beta-blockers attenuate compensatory mechanisms, reduce regurgitant volume, and preserve Left Ventricular (LV) function. Non-vitamin K antagonist oral coagulation for RHD-associated atrial fibrillation. | Mitral valve repair (preferred) or prosthetic valve replacement. Indicated for persistent heart failure, dyspnea with moderate activity, progressive cardiomegaly, or severe MR with LV systolic dysfunction. |
| Mitral Stenosis (MS) | Beta-blockers or digoxin for rate control (improves diastolic filling). Diuretics relieve pulmonary venous congestion. Vitamin K Antagonists indicated for atrial fibrillation, prior embolic event, or left atrial thrombus. | Percutaneous Mitral Valve Balloon Commissurotomy (PMBC) indicated for pliable, non-calcified valves without atrial thrombus. Surgical valvotomy or valve replacement reserved for unsuitable PMBC candidates. |
| Aortic Regurgitation (AR) | ACE inhibitors or ARBs. Antihypertensive therapy indicated for elevated systolic blood pressure. | Aortic valve repair or replacement (homograft or prosthetic). Indicated before onset of significant ventricular dysfunction, heart failure, or severe LV dilation. |
| Tricuspid Regurgitation (TR) | Decongestive measures (diuretics) for signs/symptoms of right-sided heart failure. | Tricuspid annuloplasty or repair. Typically performed concomitantly during required left-sided (mitral) valve surgery. |
Management of Complications
Heart Failure
- Workload Reduction: Restrict activity, treat fever/anemia/obesity, implement mechanical ventilation for severe cases.
- Diuretics: First-line therapy for congestive failure. Oral furosemide combined with potassium-sparing diuretics (spironolactone) to prevent arrhythmias and potassium loss.
- Afterload Reduction: ACE inhibitors (monitor creatinine/electrolytes, withhold in dehydration). Angiotensin receptor blockers (e.g., losartan) if ACE-inhibitor cough persists.
- Beta-Blockers: Carvedilol, metoprolol (improve symptoms, suppress catecholamines, prevent arrhythmias). Start low dose.
- Inotropes/Vasodilators: Sodium nitroprusside or milrinone for acute care settings. Phosphodiesterase inhibitors (milrinone) utilized cautiously due to proarrhythmic potential.
Infective Endocarditis Prophylaxis
- Indicated before procedures expected to produce bacteremia (e.g., dental procedures).
- Required for patients with established RHD or prosthetic valves.
- Routine rheumatic fever prophylaxis doses are insufficient; distinct antibiotic class required for endocarditis prevention.