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.