OVERVIEW
风湿性心脏病是风湿活动（风湿热）累及心脏时所诱发的心脏病变
可表现为心悸、气短、乏力；两颊潮红，口唇呈青紫色等
A组乙型溶血性链球菌感染导致风湿热，继而引起心脏瓣膜病变
可采用一般治疗、药物治疗、手术治疗和介入放射治疗
Definition of Rheumatic Heart Disease
Rheumatic heart disease is a heart condition that occurs when rheumatic activity (rheumatic fever) affects the heart. It includes rheumatic heart valve disease, rheumatic myocarditis, rheumatic pericarditis, or rheumatic total carditis, with rheumatic heart valve disease being the most common.
This article focuses on rheumatic heart valve disease.
Morbidity
Rheumatic fever can occur at any age, but is predominant in children between the ages of 5 and 15 years.
Rheumatic heart valve disease used to be the most common heart disease in the country, accounting for about 40% of adult cardiovascular disease.
The mitral valve lesion rate of the disease is 95% to 98%, of which 20% to 30% of patients combined with aortic valve lesions; simple mitral valve lesions are the most common, 70% to 80%.
In recent years, with the improvement of medical conditions in China and the improvement of people’s living standards, the incidence of rheumatic heart valve disease has been declining year by year.
It is common in residents of developing countries and aborigines of developed countries.
Causes
Causes
Rheumatic fever is a series of acute or chronic systemic non-suppurative inflammatory conditions of connective tissues triggered by infection with group A beta-hemolytic streptococci.
Rheumatic heart valve disease is a polygenic disorder with a risk of about 10% in siblings and 9% in children of those affected.
Predisposing factors
Cold and damp environments, overcrowded housing, poor nutrition, and poor medical care can increase the multiplication and spread of streptococci, causing rheumatic fever, which in turn leads to rheumatic heart valve disease.
Pathogenesis
The pathogenesis of rheumatic fever has not been fully clarified.
Currently, it is believed that infection with group A beta-hemolytic streptococcus in genetically susceptible individuals with rheumatic fever triggers an allergic or autoimmune response in the body, leading to a series of inflammatory conditions that attack the heart valves and cause lesions.
Heart valves may become narrowed or closed, and heart function may be normal in the early stages; after a few years, it gradually develops into cardiac insufficiency.
Symptoms
Symptoms of rheumatic heart valve disease are related to the severity of the damage to the heart valves.
Main Symptoms
In the early stages, patients with mild heart valve damage may have few or no symptoms.
In later stages, palpitations (self-perception of a fast and strong heartbeat), shortness of breath, and coughing after exertion may gradually develop.
In severe cases, there may be dyspnea, hemoptysis, coughing up foamy sputum, edema of the lower limbs, and inability to lie down at night.
Other symptoms
Early symptoms of rheumatic fever.
Fever.
Joint pain and tenderness, usually in the knees, ankles, elbows and wrists.
The pain may migrate from one joint to another.
Redness, burning or swelling of the joints.
Small, painless lumps under the skin.
Usually a history of strep throat infection 2 to 4 weeks ago with symptoms such as sore throat.
Complications
Heart failure.
May occur with severe valvular stenosis or insufficient closure.
The main symptoms are shortness of breath, dyspnea, telangiectasia, blanching, cyanosis (cyanosis of the skin and mucous membranes), irritability with frequent coughing, and coughing up pink frothy sputum.
Heart valve rupture
This is characterized by a sudden loss of consciousness, a drop in blood pressure, and cardiac and respiratory arrest. This is a medical emergency and requires surgery to replace or repair the heart valve.
Acute pulmonary edema
Early manifestations include chest tightness, panic, irritability, increased blood pressure and exertional dyspnea (difficulty breathing during physical activity).
Interstitial pulmonary edema is characterized by coughing, shortness of breath, increased heart rate, nocturnal paroxysmal dyspnea (sudden feeling of chest tightness and air congestion after sleep and awakening to sit up with coughing and shortness of breath), and may have mild cyanosis.
Alveolar edema may present with severe dyspnea, cyanosis, violent cough and coughing up a large amount of white or bloody foamy sputum, and in severe cases, respiratory and circulatory failure and metabolic dysfunction may occur.
Atrial fibrillation
Symptoms such as palpitations and chest tightness may occur.
Cerebral embolism
Facial paralysis, monoplegia of upper limbs, hemiparesis, aphasia, convulsions, etc. may occur.
Cardiac arrhythmia
Symptoms such as palpitations, shortness of breath, chest pain, irritability, etc. may occur.
Consultation
Department of Medicine
Cardiovascular Medicine
Symptoms such as fever, joint pain, palpitations, shortness of breath after exertion, cough, etc. are recommended to consult the Department of Cardiovascular Medicine promptly.
Emergency Department
For emergencies such as severe chest pain, severe palpitations, unconsciousness, convulsions, etc., it is recommended to go to the Emergency Department or call 120 emergency immediately.
Preparation for medical treatment
Preparation for medical consultation: registration, preparation of documents, common problems
Tips for seeking medical treatment
Do not abuse drugs without the doctor’s permission, so as to prevent drugs from affecting the relevant examinations and interfering with the diagnosis and treatment of the disease.
Preparation Checklist
症状清单
Pay particular attention to the time of onset of symptoms, special manifestations, etc.
Are there any symptoms such as sore throat, fever, joint pain, etc.?
How long have the symptoms lasted?
Are there any other signs of discomfort?
病史清单
Is there a family history of the disease?
Are there any drug or food allergies?
Is there a history of rheumatic fever?
Are there any other medical conditions?
检查清单
Test results in the last 6 months, which can be brought to the doctor’s office
Blood tests
Blood biochemistry
Streptococcal infection test
Echocardiogram
Chest X-ray
Cardiac Magnetic Resonance Imaging
Electrocardiogram and 24-hour ECG
用药清单
Medication use in the last 3 months, if you have a box or package, you can bring it with you to the doctor’s office
Antibiotics: penicillins, cephalosporin antibiotics
Diuretics: furosemide, hydrochlorothiazide
Cardiac stimulants: digoxin, digitalis
Anticoagulants: Warfarin
Diagnosis
Diagnosis is based on
Medical history
History of streptococcal infection.
Clinical manifestations
症状
Palpitations, shortness of breath, weakness.
Dyspnea, especially after activity or when lying down.
Chest pain.
Lower extremity edema.
Joint pain and tenderness, usually in the knee, ankle, elbow and wrist.
Pain may move from one joint to another.
Redness, burning or swelling of the joints.
Small painless lumps under the skin.
体征
Heart murmur on auscultation: Different valves are involved and abnormal heart sounds may be present. In some patients, signs of heart failure such as fine wet rales may be present at the base of both lungs.
Visualization: some patients have reddish annular erythema on the medial skin of the trunk or limbs, red, swollen joints, limited mobility, and subcutaneous nodules. Mitral facies (flushed cheeks, blue-purple lips, etc.).
Laboratory tests
链球菌感染检查
Pharyngeal swab culture, anti-streptococcal hemolysin “O”, anti-DNAase-B. The above tests confirm that the patient has had a group A streptococcal infection in the recent past.
急性炎症反应指标与免疫学检查
Erythrocyte sedimentation rate, C-reactive protein, anti-cardiac antibody, anti-group A streptococcal wall polysaccharide antibody, peripheral blood lymphocyte procoagulant activity test, the above can evaluate the rheumatic activity.
If there is rheumatic activity, anti-streptococcal hemolysin O > 500 units.
Increased erythrocyte sedimentation rate.
C-reactive protein is positive.
Serum mucin > 4 mg/dl.
Serum diphenylamine reaction > 0.25 optical density units.
Increased serum glycoproteins such as α1 > 20%.
Imaging
超声心动图检查
It is the most useful test to diagnose heart valve problems. It can detect heart valve problems such as mitral, tricuspid, and aortic valves.
It can show damage and stenosis of the valves as well as regurgitation of blood through the incompletely closed valves and enlargement of the heart.
Stay calm and do not engage in strenuous exercise before the test.
其他
Chest X-ray: can check for congestion in the lungs and look for an enlarged heart.
Cardiac Magnetic Resonance Imaging (MRI): It can check for changes in the heart valves and heart muscle.
Remove necklaces, earrings, cell phones, watches, artificial limbs, prosthetic eyes, etc. before the examination.
Electrocardiogram
Can show arrhythmia manifestations.
Before the examination, you should stay calm and refrain from smoking, drinking, and strong tea and coffee, which may cause abnormal results.
Differential Diagnosis
Coronary atherosclerotic heart disease (CHD)
Coronary artery disease is often characterized by a history of angina pectoris, myocardial infarction, or electrocardiogram. A history of left heart failure, primary hypertension, hyperlipidemia, or diabetes mellitus is helpful in the differential diagnosis.
Physical examination, X-ray, electrocardiogram, echocardiogram show signs of left ventricular hypertrophy, and coronary artery stenosis on coronary angiography may help to differentiate.
Pulmonary heart disease
Tricuspid valve disease in rheumatic heart valve disease should be differentiated from relative tricuspid valve insufficiency in chronic pulmonary heart disease.
Rheumatic heart valve disease often has a history of rheumatoid arthritis and myocarditis, and other valves, such as the mitral and aortic valves, often have lesions with specific manifestations on X-ray, electrocardiogram, and echocardiogram.
Congenital heart valve disease, syphilitic heart valve disease
Family history, history of exposure, medical history, clinical manifestations, as well as laboratory tests, X-ray chest radiographs, electrocardiograms, and echocardiograms can usually clarify the cause of heart valve disease, the valves involved, and the nature and extent of the involvement.
In a few cases, due to atypical signs, pulmonary hypertension, and special diseases, cardiac catheterization and cardiac macroangiography can be used to clarify the cause of heart valve disease.
Senile Valve Disease
Age-related valvular disease mainly refers to age-related degenerative heart valve disease, or age-related calcific heart valve disease. There are no signs of rheumatic fever such as fever, profuse sweating, or annular erythema of the skin.
Mitral Valve Prolapse Syndrome
It is a series of clinical manifestations in which the mitral valve leaflets prolapse toward the left atrium during cardiac contraction due to various reasons, resulting in mitral valve closure insufficiency.
The manifestations include weight loss, emotional abnormalities, dizziness, vertigo, fatigue, self-perception of fast and strong heartbeat after activity, chest tightness and chest pain after lying down. In severe cases, lower limb edema and nocturnal paroxysmal dyspnea may be present without rheumatic fever manifestations.
Treatment
The treatment of rheumatic heart valve disease depends mainly on the degree of damage to the heart valves. If the condition is severe, surgery may be required to replace or repair severely damaged heart valves. It is important to note that all medications should be used as prescribed by the doctor and should not be adjusted in dosage or discontinued on one’s own.
Acute phase treatment
In the presence of acute cardiac insufficiency, the cardiac insufficiency should be corrected.
Limit sodium intake.
Rest and oxygenation.
Diuresis: i.e., to help the body drain rapidly and reduce the work done by the heart.
Vasodilatation (nitrates): reduces vascular resistance and reduces the burden on the heart.
Delay structural changes in the heart: e.g. use of angiotensin-converting enzyme inhibitor (ACEI)-type drugs, beta-blockers, etc., which have a significant effect on improving prognosis.
General treatment
Keep warm, avoid humidity and cold.
Avoid strenuous physical activities, avoid acute infections as much as possible, etc. Those with congestive heart failure should also limit salt and water intake appropriately.
Bed rest, after the body temperature is normalized, the tachycardia is controlled, and the electrocardiogram is improved, continue bed rest for 3 to 4 weeks and then resume activities.
Medication
Treatment can be carried out in cardiovascular medicine. It is mainly symptomatic treatment to control rheumatic activity, cardiotonic diuretic and correct arrhythmia.
Antibiotics: usually used to treat streptococcal infections to prevent further development of rheumatic fever.
Anti-inflammatory drugs: e.g. aspirin, glucocorticoids are used to reduce inflammation in the body and reduce the risk of heart damage.
Cardiotonic and diuretic medications: cardiotonic and diuretic medications are chosen as appropriate to treat heart failure.
Antiarrhythmic drug therapy.
Anticoagulation therapy: the main aim is to prevent thrombosis and thromboembolism. If there is no clear contraindication, all should take warfarin anticoagulation therapy for a long time.
Surgical treatment
Surgical treatment in cardiac surgery is required. Depending on the circumstances, valve repair or plasty, or prosthetic valve replacement may be performed.
Valvuloplasty or valve replacement
Valvuloplasty or valve replacement is indicated in patients with severe valve damage and significant hemodynamic changes.
For patients with multiple valves, multiple valve replacement or multiple valve replacement with valvuloplasty may be performed.
Prosthetic Valve Replacement
Prosthetic valve replacement is currently the most common surgical option. Prosthetic valve replacement is used when both of the above cannot be performed.
Mechanical heart valve: A valve made entirely of artificial materials. It has superior durability and there is no need to worry about calcification. However, patients with mechanical heart valves require lifelong anticoagulation after surgery, and if strict anticoagulation therapy is not used, the incidence of thrombosis is high.
Biological heart valves: Valves made wholly or partially of biological tissue. Anticoagulation is usually given for six months to a year after surgery, but the medication is also analyzed on a case-by-case basis. Biologic valves have problems with calcification, so their lifespan is shorter than mechanical valves.
Interventional radiotherapy
Percutaneous balloon catheter mitral valvuloplasty can be performed for simple mitral stenosis.
Prognosis
Cure
The prognosis for rheumatic heart valve disease depends on the severity of the disease and the availability of timely and effective treatment.
Valve changes in rheumatic heart valve disease are irreversible and cannot be cured on their own.
Rheumatic heart valve disease can be cured by valve replacement surgery before structural and functional changes in the heart occur.
With effective treatment the progression of the disease can be slowed and the quality of life improved.
Hazards
If the disease is not treated aggressively, it can be combined with heart failure, severe arrhythmia, infective endocarditis, thromboembolism and other conditions, which can lead to adverse consequences.
Impact on normal life: when symptoms such as panic, shortness of breath, fatigue, coughing, etc. occur, it may affect daily work, study and life.
Daily
Daily management
Pay attention to the changes of climate and season, dress appropriately, prevent colds and avoid crowded places as much as possible.
Keep the living environment hygienic and wash hands frequently.
Diet should be low in salt, low in fat and high in quality protein. Vegetables and fruits rich in vitamins and fiber can be increased in moderation. One meal should not be too full, and it is appropriate to eat less and more meals.
When the patient has obvious symptoms of cardiac insufficiency or is in the active period of rheumatic fever, he should absolutely rest in bed.
When the symptoms are not obvious, you can do some light work or activities, which can effectively improve the endurance and help exercise the cardiopulmonary function, and aerobic exercise is preferred, such as walking, swimming or cycling.
Do not participate in heavy physical labor, so as not to increase the burden on the heart.
Regularly visit the hospital for follow-up and timely adjustment of medication and treatment program.
Prevention
Streptococcal infection should be treated actively. Use antibiotics as prescribed by the doctor.
Throat infections should be treated with antibiotics as prescribed by the doctor in order to avoid damage to the heart.
Rheumatic fever requires prompt treatment with antibiotics as prescribed by the doctor to prevent heart damage.
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