Rheumatic Heart Disease

What is rheumatic heart disease?

Rheumatic heart disease is long-term damage to the heart valves caused by rheumatic fever, an inflammatory illness that can develop after an untreated or inadequately treated throat infection with group A streptococcus bacteria (commonly called strep throat). When the body fights this infection, the immune system can mistakenly attack the body’s own tissues, including the heart. Over time, repeated or severe episodes of this inflammation can scar the heart valves, so they no longer open or close properly.

The heart has four valves that keep blood flowing in one direction. In rheumatic heart disease, the mitral valve (between the left upper and lower chambers of the heart) is affected most often, followed by the aortic valve (between the heart and the main artery to the body). A damaged valve may become narrowed (a problem doctors call stenosis), leaky (called regurgitation), or both. Either problem forces the heart to work harder and, over years, can lead to heart failure, abnormal heart rhythms, stroke, and other complications.

Understanding what is rheumatic heart disease starts with recognizing that it is a preventable condition. It usually begins in childhood or adolescence, when rheumatic fever is most common, but the valve damage often becomes apparent only years or decades later, in adulthood. The condition remains a significant cause of heart disease worldwide, particularly in regions where access to prompt treatment for strep throat is limited. It affects both men and women, and pregnancy can place extra strain on a heart already weakened by valve disease.

Symptoms of rheumatic heart disease

Rheumatic heart disease symptoms vary widely. Many people have no symptoms at all for years, because mild valve damage may not noticeably affect how the heart works. Symptoms usually appear gradually as the valve problem worsens and the heart struggles to pump blood efficiently.

Common rheumatic heart disease symptoms include:

• Shortness of breath — at first only during exertion, and later at rest or when lying flat.
• Fatigue — feeling unusually tired during ordinary activities.
• Chest discomfort or pain — often described as pressure or tightness.
• Palpitations — a sensation of a racing, pounding, or irregular heartbeat.
• Swelling — in the ankles, feet, legs, or abdomen, caused by fluid buildup.
• Fainting or near-fainting — especially with aortic valve involvement.
• Persistent cough or wheezing — sometimes with frothy or blood-tinged sputum when fluid backs up into the lungs.

Symptoms can also differ depending on which valve is affected and how. Mitral stenosis (a narrowed mitral valve) often causes breathlessness, fatigue, and an irregular heartbeat, and symptoms may first appear during pregnancy or physical stress. Mitral regurgitation (a leaky mitral valve) may cause few symptoms for a long time before fatigue and breathlessness develop. Aortic valve disease can cause chest pain, dizziness, or fainting on exertion.

It is also helpful to know the symptoms of acute rheumatic fever itself, since this is the illness that leads to valve damage. Rheumatic fever typically occurs a few weeks after a strep throat infection and may cause fever, painful and swollen joints (often moving from one joint to another), a rash, small lumps under the skin, and jerky, uncontrollable body movements known as chorea. Not everyone who had rheumatic fever remembers having it, so some people learn of the valve damage only when a doctor hears a heart murmur (an abnormal sound of blood flowing through the heart) during a routine examination.

Causes and risk factors

The chain of events behind rheumatic heart disease causes begins with a throat infection caused by group A streptococcus bacteria. In some people, the immune response to this infection cross-reacts with the body’s own tissues — a process called an autoimmune reaction — producing the inflammation of rheumatic fever. When this inflammation involves the heart, it is called carditis. Repeated episodes of rheumatic fever, each triggered by a new strep infection, tend to cause progressively worse valve scarring.

Factors that increase the risk of developing rheumatic fever and, in turn, rheumatic heart disease include:

• Untreated or incompletely treated strep throat — prompt antibiotic treatment of strep throat greatly reduces the risk of rheumatic fever.
• Age — rheumatic fever most often affects children and adolescents, typically between about 5 and 15 years of age.
• Repeated strep infections — each recurrence of rheumatic fever can add to existing valve damage.
• Crowded living conditions — strep bacteria spread more easily in crowded households, schools, and communities.
• Limited access to health care — where sore throats are not tested or treated, rheumatic fever is more common.
• Family or genetic factors — some people appear more susceptible to the abnormal immune reaction, though the exact reasons are not fully understood.

It is important to understand that rheumatic heart disease is not contagious. The strep throat infection that starts the process can spread from person to person, but the valve disease itself cannot. It is also not caused by lifestyle factors such as diet or exercise, although overall heart health still matters for people living with the condition.

Diagnosis of rheumatic heart disease

Rheumatic heart disease diagnosis usually begins when a doctor hears a heart murmur through a stethoscope or when a patient reports symptoms such as breathlessness or palpitations. The doctor will ask about past illnesses, including any history of rheumatic fever, frequent sore throats in childhood, or joint pains with fever.

Tests commonly used to confirm the diagnosis and assess how severe the valve damage is include:

• Echocardiogram — an ultrasound scan of the heart. This is the most important test. It shows the valves in motion, measures how narrowed or leaky they are, and assesses how well the heart is pumping. Echocardiography can detect valve changes even before symptoms appear.
• Electrocardiogram (ECG) — a recording of the heart’s electrical activity, used to detect rhythm problems such as atrial fibrillation (a common irregular heartbeat in people with mitral valve disease) and signs of chamber enlargement.
• Chest X-ray — to look for enlargement of the heart and fluid in the lungs.
• Blood tests — during a suspected episode of acute rheumatic fever, tests can look for evidence of a recent strep infection and for markers of inflammation. Blood tests may also be used to check general health before treatment decisions.
• Throat swab or culture — during an acute illness, to detect group A streptococcus bacteria.

For diagnosing acute rheumatic fever itself, doctors use an internationally recognized set of clinical criteria (often called the Jones criteria), which combine evidence of a recent strep infection with typical features such as carditis, joint inflammation, chorea, rash, and skin nodules. Once chronic valve damage is established, the focus of rheumatic heart disease diagnosis shifts to grading the severity of each valve problem and monitoring changes over time, usually with repeat echocardiograms. In some cases, additional imaging or a cardiac catheterization (a procedure in which a thin tube is passed into the heart through a blood vessel) may be needed before a procedure or surgery is planned.

Treatment options for rheumatic heart disease

Rheumatic heart disease treatment depends on which valves are affected, how severe the damage is, whether symptoms are present, and the patient’s overall health. There is no medication that can reverse valve scarring, so treatment aims to prevent further damage, control symptoms, and repair or replace valves when necessary. Care is typically coordinated by heart specialists; at Acibadem, for example, this condition is managed within the Cardiology Department, with cardiac surgeons involved when valve procedures are needed.

Preventing further damage

Because each new strep infection can trigger another episode of rheumatic fever, long-term antibiotic prophylaxis (regular preventive antibiotics, often given as periodic injections or daily tablets) is a cornerstone of care, particularly for children, adolescents, and young adults. The recommended duration varies with age, the severity of heart involvement, and individual risk, and is decided by the treating doctor.

Watchful waiting and monitoring

Many people with mild valve disease do not need any procedure. Instead, doctors recommend regular follow-up visits and periodic echocardiograms to monitor the valves. This approach, sometimes called watchful waiting, allows treatment to be timed appropriately if the disease progresses.

Medications

Medicines cannot repair a damaged valve, but they can ease symptoms and reduce complications. Depending on the individual situation, a doctor may prescribe:

• Diuretics — “water tablets” that help the body remove excess fluid and relieve breathlessness and swelling.
• Medicines to control heart rate and rhythm — for people who develop atrial fibrillation or other rhythm problems.
• Anticoagulants — blood-thinning medicines that reduce the risk of blood clots and stroke, often needed with atrial fibrillation or after certain valve replacements.
• Heart failure medicines — when the heart’s pumping function is reduced.
• Anti-inflammatory treatment — during an episode of acute rheumatic fever, to control inflammation, alongside antibiotics to clear the strep infection.

Procedures and surgery

When valve damage is severe or symptoms cannot be controlled with medicines, a procedure or operation may be recommended:

• Balloon valvuloplasty — a minimally invasive procedure, most often used for mitral stenosis, in which a thin tube with a small balloon is guided into the heart and inflated to widen the narrowed valve. It is suitable only when the valve anatomy allows.
• Valve repair surgery — an operation to reshape and preserve the patient’s own valve. Repair is preferred when technically feasible.
• Valve replacement surgery — when a valve is too damaged to repair, it can be replaced with a mechanical valve (which usually requires lifelong blood-thinning medication) or a biological valve made from animal or human tissue (which may wear out over time and need replacement later). The choice depends on age, lifestyle, other health conditions, and personal preferences, and is discussed carefully between patient and doctor.

The right combination of these options differs from person to person, and decisions are usually made by a heart team that includes cardiologists and cardiac surgeons.

Living with rheumatic heart disease and outlook

The outlook for someone with rheumatic heart disease depends largely on how severe the valve damage is, whether further episodes of rheumatic fever can be prevented, and how consistently the condition is monitored and treated. Many people with mild disease live full, active lives with regular check-ups and no procedures. Others eventually need valve repair or replacement, after which many experience significant improvement in symptoms, although lifelong follow-up remains necessary. No treatment can guarantee a specific outcome, and outcomes vary from person to person.

Practical points that often help people living with the condition include:

• Taking preventive antibiotics as prescribed — this is one of the most effective ways to stop the disease from getting worse in younger patients.
• Attending all follow-up appointments — regular echocardiograms allow doctors to act before complications develop.
• Good dental and general hygiene — damaged valves are more vulnerable to infective endocarditis, an infection of the heart’s inner lining; keeping teeth and gums healthy and telling dentists about the condition can reduce this risk.
• Managing medications carefully — especially blood thinners, which require monitoring and attention to interactions with food and other drugs.
• Discussing pregnancy plans with a doctor — pregnancy increases the workload of the heart, so women with rheumatic heart disease benefit from specialist assessment before and during pregnancy.
• Staying generally heart-healthy — not smoking, eating a balanced diet, and keeping physically active within limits agreed with the doctor.

Living with a chronic heart condition can also be emotionally demanding. It is reasonable to ask the care team about support resources, and to involve family members in understanding the condition and its treatment.

Frequently asked questions

What is rheumatic heart disease in simple terms?

It is lasting damage to the heart valves caused by rheumatic fever, an inflammatory illness that can follow an untreated strep throat infection. The immune system’s reaction to the infection injures the valves, which over time may become scarred, narrowed, or leaky, making the heart work harder than normal.

Can rheumatic heart disease be cured or heal on its own?

Scarred heart valves do not heal on their own, and no medication can undo the damage. However, further damage can often be prevented with regular antibiotics, symptoms can usually be managed with medicines, and severely damaged valves can in many cases be repaired or replaced with procedures or surgery. With appropriate care, many people do well over the long term.

How serious is rheumatic heart disease?

Severity ranges from mild valve changes that cause no symptoms to severe disease that leads to heart failure, irregular heart rhythms, or stroke if untreated. The seriousness for any individual depends on which valves are affected, how badly, and how the condition is managed. Regular monitoring allows doctors to intervene at the right time, which generally improves the outlook.

What are the first symptoms of rheumatic heart disease?

Early rheumatic heart disease often causes no symptoms at all. When symptoms do appear, the most common early signs are breathlessness during exertion, unusual tiredness, and palpitations. Some people first learn of the condition when a doctor hears a heart murmur during an examination for another reason.

What causes rheumatic heart disease and can it be prevented?

The root cause is rheumatic fever following a group A strep throat infection. Prompt antibiotic treatment of strep throat greatly reduces the risk of rheumatic fever, and long-term preventive antibiotics help protect people who have already had rheumatic fever from repeat episodes that would worsen valve damage. In this sense, the condition is largely preventable.

Is rheumatic heart disease contagious?

No. The valve disease itself cannot be passed from person to person. The strep throat infection that can start the process is contagious, which is why treating sore throats promptly and practicing good hygiene matter, especially in households with children.

What is recovery like after valve surgery for rheumatic heart disease?

Recovery varies with the type of procedure, the person’s age, and overall health. After open-heart valve surgery, hospital stays and a gradual return to normal activities over weeks are typical, often supported by cardiac rehabilitation. Minimally invasive procedures such as balloon valvuloplasty usually involve shorter recovery times. Lifelong follow-up, and in some cases blood-thinning medication, is generally needed after valve replacement. Your doctor can explain what to expect in your specific situation.

When to see a doctor

Anyone with a history of rheumatic fever, a known heart murmur, or symptoms suggesting valve disease should be evaluated by a doctor and kept under regular follow-up. Children and adolescents with a sore throat and fever should be assessed promptly, since treating strep throat early can prevent rheumatic fever in the first place.

Seek urgent medical attention if you or someone you care for experiences any of the following red-flag warning signs:

• Severe or worsening shortness of breath, especially at rest or when lying flat, or waking at night gasping for air.
• Chest pain or pressure that is new, severe, or does not go away.
• Fainting or collapse, or repeated episodes of dizziness or near-fainting.
• A very fast, pounding, or irregular heartbeat that is new or accompanied by other symptoms.
• Signs of stroke — sudden weakness or numbness on one side of the body, facial drooping, trouble speaking, or sudden vision loss.
• Rapidly increasing swelling of the legs, ankles, or abdomen, or sudden weight gain from fluid.
• Unexplained fever in someone with known valve disease or a replaced valve, which can be a sign of infective endocarditis.
• Coughing up blood or frothy pink sputum.

These symptoms may indicate a serious complication such as heart failure, a dangerous heart rhythm, a stroke, or a heart valve infection, all of which need prompt assessment and treatment. If in doubt, it is always safer to be examined by a medical professional.