Rheumatic fever and rheumatic heart diseases

Rheumatic fever and rheumatic heart diseases

Saxena, Anita

Rheumatic fever and rheumatic heart diseases (World Health Organization, Geneva) 2004. 122 pages. Price: Sw.fr.23/- US $ 20.70 in developing countries: Sw.fr. 16.10 ISBN 92-4-120923-2

Rheumatic fever (RF) and rheumatic heart disease (RHD) remain major public health problems in India and other developing countries. The WHO Technical Report Series No. 923, published in 2004 is a welcome publication to all paediatricians, physicians and cardiologists of the country. This publication summarizes the report of a WHO expert consultation, met in WHO Headquarters, Geneva, from October 29 to November 1, 2001. This is an update on the previously published WHO Technical Report 764 on rheumatic fever and rheumatic heart disease in 1988. World renowned experts in the field of rheumatic fever constituted the panel. There were several members from the countries where RF and RHD are still rampant. This book covers almost all aspects of rheumatic fever and rheumatic heart disease starting with epidemiology. The chapter on epidemiology focuses on the incidence of RHD in various countries of different continents. The role of environmental factors in determining the epidemiology is also highlighted. The involvement of beta haemolytic streptococci in the pathogenesis of RF is well explained in the second chapter. Recent changes in the agent, host and the environment as seen in some regions of the world, are also discussed.

The chapter on diagnosis of rheumatic fever disuses the modifications and updates on the original Jones criteria. The expert group has proposed 20022003 WHO criteria for diagnosis of RF and RHD. The various diagnostic categories have been separated and guidelines set for diagnosing each one of them, e.g., criteria for diagnosing primary episode of rheumatic fever, criteria for recurrent attack of rheumatic fever in patient without previously established RHD, etc. Hence these guidelines cover several categories of rheumatic fever where Jones criteria cannot be applied. The book also discusses the role of echocardiography in diagnosis of acute carditis. It has been well pointed out that although echocardiography offers several advantages in diagnosis of valvulitis, it is not feasible to use this technique in developing countries with huge burden of the disease and limited resources. This puts to rest the controversy regarding use of echocardiography for diagnosis of rheumatic fever. Clinical assessment remains the basis for diagnosis of this disease.

Subsequent chapters discuss the chronic valvular lesions as a result of rheumatic heart disease, including the subgroup of pregnancy in women with RHD. Mitral valve lesions are most common and are discussed in detail. Aortic stenosis secondary to RHD is not common. Medical management of RF has been discussed in brief. The controversy whether to use acetylsalicylic acid or corticosteriods has not been written in detail; there are several articles recently published, addressing this issue. Indications and contraindication to surgery for chronic valvular heart disease have been discussed in depth. The later part of the chapter on surgical management deals with role of surgery during active rheumatic carditis. The expert panel concludes that surgery can be safely performed during active carditis and may be preferred in refractory cases. Valve replacement is preferable to valve repair as valve repair is associated with significant reoperation rates.

The issue of prevention of rheumatic fever has been discussed at length in the book. Starting with primary prevention using antibiotics, the experts go on to describe the strategies and principles of secondary prevention. Use of injectable long acting penicillin is recommended and preferred over oral penicillin, sulphonamides and erythromycin. The duration of secondary prophylaxis in various settings is highlighted. It has been reiterated that serious reaction to penicillin injection in under 12 children is rare and long term benefits of benzathin penicillin therapy in preventing rheumatic fever far outweigh the risk of a serious allergic reaction. Regarding successful development of a streptococcal vaccine in near future, experts expressed some degree of skeptism. They feel that vaccine may be developed in the next 5-10yr, but questions regarding the safety, cost-effectiveness and efficacy in varied epidemiologic and socio-economic conditions are likely to remain unanswered.

Finally, planning of national programme in countries where rheumatic fever and rheumatic heart disease remain significant health concerns is discussed in brief. A very important issue is to implement such programme using the exiting national infrastructure. As highlighted by the panel of experts, this would minimize the additional costs in already resource – poor countries.

The text of this monograph is exhaustive and written with utmost clarity. This monograph will be extremely useful and serve the needs of each and everyone involved in the care ot children, adolescents and adults with rheumatic fever and rheumatic heart disease.

Anita Saxena

Professor of Cardiology

Cardio thoracic Science Centre

All India Institute of Medical Sciences

New Delhi 110029, India

Copyright Indian Council of Medical Research Apr 2006

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