ORIGINAL RESEARCH PAPER Volume - 12 | Issue - 04 | April - 2023 | PRINT ISSN No. 2277 - 8179 | DOI : 10.

36106/ijsr

INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH

FACTORS PRECIPITATING HEART FAILURE IN PATIENTS WITH RHEUMATIC

HEART DISEASE IN TERTIARY CARE TEACHING HOSPITAL.

General Medicine
Dr. Akash Gangane Post Graduate Resident, Department of Medicine, PCMC's PGI, YCMH PIMPRI Pune
Dr. Narendra Kale Associate Professor, Department of Medicine, PCMC's PGI, YCMH PIMPRI Pune
Professor and HOD, Department of Medicine, PCMC's PGI, YCMH PIMPRI Pune
Dr. Pravin Soni* *Corresponding Author
Dr Yaminy Associate professor in department of pathology Dr. D.Y. Patil Medical College, Hospital
Pradeep Ingale and Research Centre, Dr. D. Y. Patil Vidyapeeth, PIMPRI, PUNE
ABSTRACT
Introduction: Streptococcus pyogenes group A beta-hemolytic produces rheumatic heart disease, a chronic condition. In countries with low and
intermediate incomes, it signicantly increases morbidity and mortality. Aims and objectives: To assess the precipitating causes for Frank
congestive cardiac failure in patients with established RHD and evaluate the diagnostic problems of fresh rheumatic activity versus infective
endocarditis. Methodology: This was a hospital-based prospective, observational study conducted on 150 patients with RHD with cardiac failure
admitted to the tertiary care centre in the hospital in the department of general medicine. Results: In patients (≤20 years) Fresh Rheumatic Activity
(FRA) was the single most important factor in 85.7%, followed by infection (47.8%) while in patients >20 years, infective endocarditis (92.9%),
strenuous physical activity (84.2%) and irregular treatment (72.4%), were a few of the more common factors responsible for precipitation of CCF
as compared with patients ≤20 years of age. Conclusion: FRA and infective endocarditis were the most common precipitating factors in patients
≤20 years and >20 years respectively.
KEYWORDS
Rheumatic Heart Disease, Fresh Rheumatic Activity, Infective Endocarditis
INTRODUCTION institutional ethics committee and review board, as well as the patients'
Chronic rheumatic heart disease is brought on by group A beta- written informed consent.
hemolytic Streptococcus pyogenes and develops years after acute
rheumatic fever. Around the world, it results in 250,000 young The sample size was calculated using the formula N = (Z2 × P x (1 –
individuals dying each year. Rheumatic heart disease affects roughly P))/d2, with 95% condence limits and precision error of estimation at
15 million people worldwide.1 The frequency is higher in children 4%.
between the ages of 5 and 15 and in underdeveloped or developing
nations where pharyngitis is uncommonly treated with antibiotics and N = (3.84 × 0.05 x 0.95)/0.0016 = 134. Hence 150 patients were
where compliance is low.2 enrolled in the study

Congestive heart failure caused by valve involvement is the persistent Inclusion Criteria
symptom of rheumatic heart disease. The mitral valve is typically Ÿ Adults in the age group of 18-60
impacted, leading to mitral stenosis or mitral regurgitation. Depending Ÿ All patients with RHD with cardiac failure admitted to the hospital
on the level of valvulitis and myocarditis present, rheumatic fever can whom onset or aggravation of heart failure in the last 30 days
produce acute symptoms of pericarditis and congestive heart failure. In
acute rheumatic fever, migratory polyarthritis is the most prevalent Exclusion Criteria:
symptom. Along with a rash that starts on the trunk and spreads to the Ÿ Pregnant women and minors
limbs, subcutaneous nodules also appear across the bones and tendons. Ÿ Patients suffering from congenital heart disease, ischemic heart
Erythema marginatum is the name given to the rash, which has a disease, valvular heart disease, hypertension, diabetes mellitus
distinctive erythematous ring around a pale core. St. Vitus' dance, also Ÿ Patients incapable of giving consent (psychiatric patients)
known as Sydenham's chorea, is characterized by involuntary, swift Ÿ Persons unwilling to undergo the study (who refused to consent)
movements of the arms and facial muscles. The majority of the time,
rheumatic heart disease is dormant or quiet until late age, when cardiac A complete medical history was taken, including the age at which the
issues appear. The most frequent side effects are atrial brillation due RA began, whether morning stiffness was present and for how long,
to untreated severe valvular disease, infectious endocarditis, an chest symptoms, a list of the painful joints, whether there were any
embolic event, heart failure and pulmonary hypertension.3 other systemic diseases present, and any extra-articular signs of the
RA. A neurological, respiratory, gastrointestinal, and cardiovascular
Patients with a known diagnosis of rheumatic fever should be closely examination was performed. Stienbrocker's scale was used to record
monitored by primary care doctors and practitioners, and this should the patients' functional status.
be stressed. Patients should be closely monitored, have thorough
physicals and histories taken, and have transthoracic echocardiograms All joints were thoroughly examined for signs of activity, and
in order to prevent rheumatic heart disease. RHD is still an untreated estimates for the number of sensitive joints and swollen joints were
cardiovascular disease that signicantly affects morbidity and made. Fuch's et al.4 described a simplied 28 joint articular index that
mortality in low- and middle-income countries. was used to evaluate disease activity. In addition, measurements of the
ESR, Rheumatoid factor (IgG), hemoglobin, blood urea, serum
Hence the present study was conducted at our tertiary care centre to creatinine, and blood sugar were made.
assess the precipitating causes for Frank congestive cardiac failure in
patients with established RHD and evaluate the diagnostic problems of M-mode, two-dimensional, and Doppler echocardiography were done
fresh rheumatic activity RA versus infective endocarditis. using a Hewlett Packard Sonos 2500 scanning device with the patient
lying supine and to the patient's left. All research participants had a 12-
MATERIAL AND METHODS lead ECG. All patients and controls underwent routine PA view chest
A hospital based prospective, observational study was conducted on X-rays.
150 patients with RHD with cardiac failure admitted to the tertiary care
centre in the hospital in the department of general medicine. These OBSERVATIONS AND RESULTS
patients had an onset or aggravation of heart failure in the last 30 days. The data was obtained and analysed using appropriate statistical
The study was carried out after receiving proper approval from the software, including but not restricted to MS Excel, SPSS ver. 20 was
International Journal of Scientific Research 1
Volume - 12 | Issue - 04 | April - 2023 PRINT ISSN No. 2277 - 8179 | DOI : 10.36106/ijsr

used for statistical analysis. (87.3%) patients had past history of palpitation and fever respectively.
115 (76.7%) and 103 (68.7%) patients had past history of oedema over
Distribution Of Patients According To Age feet and previous admission respectively while 91 (60.7%), 4 (2.7%)
Majority of the patients (32%) were in the age group of 11-20 years and 2 (1.3%) patients had past history of sore throat, rheumatic chorea
followed by 28% in the age group of 21-30 years, 20% in the age group and tonsillectomy respectively.
of 31-40 years, 10% in the age group of 41-50 years, 4.8% in the age
group of 1-10 years, 4% in the age group of 51-60 years and 0.6% in the Distribution Of Patients According To Associated Diseases
age groups of 61-70 years and 71-80 years. 5 (3.3%) patients had uraemia while 2 (1.2%) and 1 (0.6%) patient had
cirrhosis of liver and pericardial effusion respectively.

Figure 1: Distribution of patients according to Age Figure 3: Distribution of patients according to Associated Diseases

Distribution Of Patients According To Sex Table 3: Distribution of patients according to Type of Valvular
59 (39.3%) patients were male while 91 (60.7%) patients were female Lesion
in our study group. The M:F ratio was 1:1.54. Type of Valvular Lesion N %
Mitral stenosis 79 52.8%
Mitral stenosis + Mitral incompetence 34 22.8%
Mitral + Aortic valve disease 32 21.4%
Mitral incompetence 3 1.8%
Aortic incompetence 1 0.6%
Aortic incompetence + Aortic stenosis 1 0.6%
Total 150 100%
The most common valve involved in valvular lesion was mitral
stenosis (52.8%) followed by mitral stenosis with mitral incompetence
Figure 2: Distribution of patients according to Sex (22.8%), mitral + aortic valve disease (21.4%), mitral incompetence
(1.8%), aortic incompetence (0.6%) and aortic incompetence + aortic
Table 1: Distribution of patients according to Presenting stenosis (0.6%).
Symptoms
Presenting Symptoms N % Table 4: Distribution of patients according to Precipitating
Breathlessness 150 100% Factors for Congestive Cardiac Failure (CCF)
Cough with expectoration 145 96.7% Precipitating Factors ≤20 >20 Total p
Swelling over legs 141 94% years years Value
Palpitation 140 93.3% N % N % N %
Chest pain 118 78.7%
Orthopnea 105 70% Pulmonary Bronchitis 11 47.8% 12 52.2% 23 15.3% >0.05
Pain in abdomen 89 56.3% infection Pneumonia 1 25% 3 75% 4 2.7%
Fever 77 51.3% (n=30; 20%) Pulmonary TB 0 - 3 100% 3 1.8%
Pain in joint 35 23.3% Other Enteric 1 50% 1 50% 2 1.3% >0.05
Vomiting 17 11.3% infections Malaria 4 44.4% 5 55.6% 9 6%
Neurological complaint 13 8.7% (n=15; 10%) UTI 1 25% 3 75% 4 2.7%
Hemoptysis 10 6.7% Fresh Rheumatic Activity 30 85.7% 5 14.3% 35 23.3% <0.05
Abnormal movements 2 1.3% (FRA)
Others 32 21.3% Infective Endocarditis 1 7.1% 13 92.9% 14 9.3% <0.05
The most common symptom was breathlessness (100%) followed by Tachyarrhythmias 15 36.6% 26 63.4% 41 27.3% <0.05
cough with expectoration (96.7%), swelling over legs (94%), Pulmonary embolism 0 - 3 100% 3 1.8% <0.05
palpitation (93.3%), chest pain (78.7%), orthopnea (70%), pain in Thyrotoxicosis 0 - 4 100% 4 2.7% <0.05
abdomen (56.3%), fever (51.3%), pain in joint (23.3%), vomiting Eosinophilia 0 - 2 100% 2 1.3% <0.05
(11.3%), neurological complaint (8.7%), hemoptysis (6.7%) and Prosthetic valve 0 - 2 100% 2 1.3% <0.05
abnormal movements (1.3%). 32 (21.3%) patients had others dysfunction
symptoms. Pregnancy 2 28.6% 5 71.4% 7 4.7% <0.05
Excessive physical activity 6 15.8% 32 84.2% 38 25.3% <0.05
Table 2: Distribution of patients according to Past History Irregular/Inadequate anti 22 28.9% 54 71.1% 76 50.7% <0.05
Past History N % failure treatment
Breathlessness 145 96.7% No salt restriction 14 14% 86% 100 66.7% <0.05
Arthritis 140 93.3%
Palpitation 137 91.3% 100 (66.7%) patients did not take salt restricted diet while 76 (50.7%)
Fever 131 87.3% patients were taking irregular and inadequate anti failure treatment. 41
Oedema over feet 115 76.7% (27.3%) patients had tachyarrhythmia and 38 (25.3%) patients
developed CCF after strenuous physical activity. It was observed in
Previous admission 103 68.7%
younger patients (≤20 years) that Fresh Rheumatic Activity (FRA) was
Sore throat 91 60.7% the single most important factor in 85.7% patients responsible for
Rheumatic chorea 4 2.7% precipitating CCF in established cases of RHD followed by infection
Tonsillectomy 2 1.3% (47.8%), tachyarrhythmia (36.6%), irregular and inadequate treatment
145 (96.7%) and 140 (93.3%) patients had past history of (28.9%) and pregnancy (28.6%) compared to patients with age more
breathlessness and arthritis respectively while 137 (91.3%) and 131 than 20 years. In patients >20 years, infective endocarditis (92.9%),
2 International Journal of Scientific Research
Volume - 12 | Issue - 04 | April - 2023 PRINT ISSN No. 2277 - 8179 | DOI : 10.36106/ijsr

strenuous physical activity (84.2%), irregular treatment (72.4%), DISCUSSION

tachyarrhythmia (63.4%), infection (52.2%), other infections like In order to determine the causes of cardiac failure in individuals with
enteric fever (50%), malaria (55.6%), UTI (75%), pulmonary conrmed instances of rheumatic heart disease, a prospective,
embolism (100%), thyrotoxicosis (100%), eosinophilia (100%), observational study was carried out at a hospital with 150 patients.
prosthetic valve dysfunction (100%), pregnancy (71.4%) and no salt Most industrialized, high-income countries and many other regions of
restriction in diet (86%) were responsible for precipitation of CCF as the world with improved human development indices and healthcare
compared with patients ≤20 years of age. Fresh Rheumatic Activity systems have seen a substantial drop in rheumatic heart disease
(FRA) was seen in only 5 (14.3%) patients which indicates its (RHD). Rural poor and marginalized communities continue to
uncommon occurrence after the age of 20 years. experience the disease and have limited or no access to basic
healthcare5,6
Table 5: Clinical profile of patients with FRA (n=35)
Clinical prole N % In the present study, majority of the patients (32%) were in the age
group of 11-20 years followed by 28% in the age group of 21-30 years.
Fever 35 100%
(Figure 1) A female predominance (60.7%) was observed. With the
Past history of ARF 35 100%
male: female ratio being 1:1.54. (Figure 2) This was in concordance to
ESR>20mm fall in 1st hour 35 100% results obtained in studies by Cannon J et al7, Mathur KS et al8, and
Hb<10 gms% 35 100% Okello E et al9. Roy SB et al10 studied prevalence of rheumatic fever
TLC>11000/cmm 33 94.3% and rheumatic heart disease reported RHD was found to be 2.2/1000 in
Arthralgia 25 71.4% 5 to 30-year-old subjects. In a study by Berry JN11, RHD was
Carditis 21 60% discovered in 1.23 per 1000 males and 2.07 per 1000 females across all
Palpable spleen 15 42.8% age categories in a study of the metropolitan population.
Arrythmia 11 31.4%
Prolonged PR interval 10 28.6% The most common symptom in our study was breathlessness (150%)
Arthritis 8 22.8% followed by cough with expectoration (96.7%), swelling over legs
Chorea 2 1.3% (94%), and palpitation (93.3%). (Table 1). This was comparable to the
study of Okello E et al9 who found cardiovascular symptoms, including
Out of 35 patients with Fresh Rheumatic Activity (FRA), 30 (85.7%) palpitations, fatigue, chest pain, oedema and syncope in 85.1% of the
patients were ≤20 years of age. 35 (100%) patients had fever, past patients.
history of ARF and were found to be anemic with ESR>20mm fall in
1st hour. 33 (94.3%) patients had TLC>11000/cmm while 25 (71.4%) For the diagnosis of RHD, a thorough physical examination,
and 21 (60%) patients had arthralgia and carditis respectively. 15 auscultation, study of the patient's history and current symptoms, and
(42.8%) and 11 (31.4%) patients had palpable spleen and arrythmia search for heart failure symptoms are essential12.It was observed in the
respectively while 10 (28.6%), 8 (22.8%) and 2 (1.3%) patients had present study that 145 (96.7%) and 140 (93.3%) patients had past
prolonged PR interval, arthritis and chorea respectively. history of breathlessness and arthritis respectively while 137 (91.3%)
and 131 (87.3%) patients had past history of palpitation and fever
Table 6: Correlation of Recurrence of Rheumatic Heart Disease to respectively. (Table 2) Similar ndings were made by Okello E et al9 in
Prophylactic Penicillin and Anti-failure Therapy (n=35) their study, which included 350 patients, of which 41 already had a
Category ≤20 years >20 years Total diagnosis of RHD, and 309 who were given a conrmed RHD
N % N % N % diagnosis for the rst time.
Patient taking regular 7 100% 0 - 7 20%
penicillin prophylaxis It was observed in our study that 5 (3.3%) patients had uraemia while 2
Patient taking irregular 15 88.2% 2 11.8% 17 48.6% (1.2%) and 1 (0.6%) patient had cirrhosis of liver and pericardial
penicillin prophylaxis effusion respectively. (Figure 3) In the cross-sectional investigation by
Okello E et al9, 49% (152/309) of the newly diagnosed RHD subjects
Patient not taking therapy 8 72.7% 3 27.3% 11 31.4% had problems. The most frequent complication was heart failure
It was observed that 7 (20%) patients below the age of ≤20 years with (46.9%), which was followed by pulmonary hypertension (32.7%) and
FRA were taking regular penicillin prophylaxis. Among 17 (48.6%) atrial brillation (13.9%). In the present study, the most common valve
patients with FRA taking irregular penicillin prophylaxis, 15 (88.2%) involved in valvular lesion was mitral stenosis (52.8%) followed by
and 2 (11.8%) patients were at the age of ≤20 years and >20 years mitral stenosis with mitral incompetence (22.8%) (Table 3). Similar
respectively. observations were noted in the studies of.Okello E et al9 and Sliwa K et
al13 who mitral regurgitation as the most common valvular lesion.
Among 11 (31.4%) patients with FRA not taking therapy, 8 (72.7%)
and 3 (27.3%) patients were at the age of ≤20 years and >20 years In our study, it was observed in younger patients (≤20 years) that Fresh
respectively. The correlation of recurrence of rheumatic heart disease Rheumatic Activity (FRA) was the single most important factor in
to prophylactic penicillin and anti-failure therapy noted lesser 85.7% patients responsible for precipitating CCF in established cases
incidence of rheumatic activities in patients on regular penicillin of RHD followed by infection (47.8%). While in patients >20 years,
prophylaxis. infective endocarditis (92.9%), strenuous physical activity (84.2%)
and irregular treatment (72.4%), were a few of the more common
Clinical profile of patients with Infective Endocarditis (n=14) factors responsible for precipitation of CCF as compared with patients
Out of 14 patients with infective endocarditis, 13 (92.9%) patients ≤20 years of age. FRA was seen in only 5 (14.3%) patients which
were >20 years of age. 14 (100%) patients had unexplained fever >7 indicates its uncommon occurrence after the age of 20 years. This is
days, pallor and palpable spleen. 9 (64.3%) patients each had absent similar to the studies of Okello E et al9, Agarwal BL et al14, Vaishnava S
pulsations and negative blood culture while 7 (50%) patients each had et al15 and Oran B et al16. (Table 4)
clubbing and hematuria.
According to a cross-sectional study by Okello et al9, Atrial brillation
was shown to be the most frequent complication associated with
congestive heart failure (81.4% CHF vs 18.6% no CHF), followed by
acute rheumatic fever recurrence (71.4% CHF vs 28.6% no CHF), and
infective endocarditis (78.6% CHF vs 21.4% no CHF). Agarwal BL et
al14 and Vaishnava S et al15 observed virulence of RF is related to its
capacity to cause cardiac damage.

It was observed in our study that out of 35 patients with Fresh

Rheumatic Activity (FRA), all had fever, had a past history of ARF,
were found to be anemic with ESR>20mm fall in 1st hour. 94.3% and
71.4% had TLC>11000/cmm and arthralgia respectively. (Table 5). In
Figure 4: Clinical prole of patients with Infective Endocarditis the present study, 7 (20%) patients below the age of ≤20 years with
(n=14) FRA were taking regular penicillin prophylaxis. Among the irregularly
International Journal of Scientific Research 3
Volume - 12 | Issue - 04 | April - 2023 PRINT ISSN No. 2277 - 8179 | DOI : 10.36106/ijsr

consuming penicillin prophylaxis patients, 88.2% and 11.8% were at 8. Mathur KS, Banerji SC, Nigam DK et al. Rheumatic heart disease and rheumatic fever-
prevalence in a village community of Bichpuri Block Agra. J Assoc Physicians India.
the age of ≤20 years and >20 years respectively. Among those with 1971;19:151–156.
FRA not taking therapy, 72.7% were ≤20 years. (Table 6) The 9. Okello E, Wanzhu Z, Musoke C et al. Cardiovascular complications in newly diagnosed
correlation of recurrence of rheumatic heart disease to prophylactic rheumatic heart disease patients at Mulago Hospital, Uganda. Cardiovasc J Afr.
2013;24(3):80-85
penicillin and anti-failure therapy noted lesser incidence of rheumatic 10. Roy SB. Prevalence of rheumatic fever and rheumatic heart disease in Ballabhgarh.
activities in patients on regular penicillin prophylaxis. Annual Report, Indian Council of Medical Research. 1968-1969:52.
11. Berry JN. Prevalence survey of chronic rheumatic heart disease and rheumatic fever in
Northern India. Br Heart J. 1972;34:134–149.
It's crucial to be aware that oral penicillin could not work to prevent 12. Nishimura RA, Otto CM, Bonow RO et al. 2017 AHA/ACC focused update of the 2014
RF17 Even in households with educated members, compliance with a AHA/ACC guideline for the management of patients with valvular heart disease: a
10-day oral therapy is uncertain. Therefore, it is crucial to take report of the American College of Cardiology/ American Heart Association Task Force
on Clinical Practice Guidelines. Circulation. 2017;135:e1159–e1195.
injectable penicillin to stop RF. 400,000 units of procaine penicillin 13. Sliwa K, Carrington M, Mayosi BM et al. Incidence and characteristics of newly
administered twice daily for ten days is the recommended penicillin diagnosed rheumatic heart disease in urban African adults: insights from the heart of
dosage.18 Identication of people who have RF or RHD is necessary for Soweto study. Eur Heart J. 2010;31:719-727
14. Agarwal BL, Agrawal R. Rheumatic fever. Clinical prole of the initial attack in India.
secondary prevention, and once they have been diagnosed, the patient Bull World Health Organ. 1986;64:573–578.
needs to receive injections of benzathine penicillin once every two to 15. Vaishnava S, Webb JK, Cherian J. Juvenile rheumatism in South India. A clinical study
three weeks, depending on their age, size, and muscle mass. Because of 166 cases. Indian J Child Health. 1960;9:290–299.
16. Oran B, Coban H, Karaaslan S et al. Serum cardiac troponin-I in active rheumatic
RF has a propensity for recurrence in people who have already had it, carditis. Indian J Pediatr. 2001;68:943–944.
penicillin prophylaxis is essential. Every additional attack worsens the 17. Veasy LG, Wiedmeier SE, Orsmond GS et al. Resurgence of acute rheumatic fever in the
condition by causing more damage to the valve tissue. Secondary intermountain area of the United States. N Engl J Med. 1987;316:421–427.
18. Dajani A, Taubert K, Ferrieri P et al. Treatment of acute streptococcal pharyngitis and
prevention can lessen the initial damage but cannot stop recurrences.19 prevention of rheumative fever: a statement for health professionals. Committee on
Rheumatic fever, Endocarditis and Kawasaki Disease of the Council on Cardiovascular
In our study, out of 14 patients with infective endocarditis, 13 (92.9%) disease in the young, the American Heart Association. Pediatrics. 1995;96:758–764.
19. Feinstein AR, Spagnuolo M. Mimetic features of rheumatic-fever recurrences. N Engl J
patients were >20 years of age. 14 (100%) patients had unexplained Med. 1960;262:533–540
fever >7 days, pallor and palpable spleen. 9 (64.3%) patients each had
absent pulsations and negative blood culture while 7 (50%) patients
each had clubbing and hematuria. (Figure 4)

Improved ARF detection and quick treatment beginning may delay the
development of RHD, which is why these measures are highly
desirable. Although fever is non-specic, up to one-third of ARF
patients cannot recall ever having a sore throat.

CONCLUSION
We conducted a study with 150 patients to assess the factors
precipitating cardiac failure in patients with established cases of
rheumatic heart disease (RHD). We noted that the incidence of RHD in
2nd, 3rd and 4th decade of life was 32%, 28% and 20% respectively and
incidence was found to be higher in females than males with M:F ratio
of 1: 1.6. In valvular lesion, commonest valve involved was mitral
valve with MS in 52% cases. Heart failure was more common in
patients with old age, who consumed more salt, patients with anemia,
tachyarrhythmia, poor drug compliance, infection and pregnancy. In
patients (≤20 years) Fresh Rheumatic Activity (FRA) was the single
most important factor in 85.7%, followed by infection (47.8%) while
in patients >20 years, infective endocarditis (92.9%), strenuous
physical activity (84.2%) and irregular treatment (72.4%), were a few
of the more common factors responsible for precipitation of CCF as
compared with patients ≤20 years of age.

Conflict Of Interest
The Authors have no conicts of interest that are directly relevant to
the content of this clinic-pathological case

Financial Resources
There are no nancial resources to fund this study \

Informed Consent
Informed Consent was obtained from the patient.

Author's Contribution
All the authors contributed equally to the case report.

Data And Materials Availability

All data associated with this study done at PCMC'S PGI YCM hospital
are present in the paper.

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4 International Journal of Scientific Research