Use of Doppler echocardiography to support the decision to discontinue secondary prophylaxis for patients with rheumatic fever and normal cardiac auscultation.

Secondary prophylaxis remains the safest way to prevent or minimize heart valve damage in patients with rheumatic fever. However, criteria to determine the duration of prophylaxis have not been well established. This study aimed to evaluate the clinical and Doppler echocardiographic profile of patients with rheumatic fever and a normal clinical examination at least 5 years after the first episode and to discuss the contribution of Doppler echocardiography in supporting the decision to discontinue secondary prophylaxis. An observational longitudinal study analyzing 183 patients with rheumatic fever and a normal clinical examination 5 years or more after the initial attack was conducted. The patients underwent Doppler echocardiography to study the severity of mitral or aortic valvular disease. Of the 183 patients, 77 (42 %) had clinical carditis. Subclinical chronic heart disease occurred for 79 % of the patients with previous clinical carditis and for 25 % of the patients without clinical carditis. Of the 35 patients with previous clinical carditis who were in the period of discontinued prophylaxis, residual valvular heart disease was observed in all, whereas of the 62 patients without clinical carditis, only 27 % showed residual valvular heart disease. Considering Doppler echocardiographic criteria, prophylaxis would be continued for 13 (34 %) of the patients with previous clinical carditis and for only 2 (3 %) of those without clinical carditis. Return of cardiac auscultation to normal is not always accompanied by return of Doppler echocardiographic findings to normal. Criteria regarding Doppler echocardiographic findings and valve morphology should be evaluated by the time secondary prophylaxis is discontinued. However, further studies are needed to demonstrate whether prolonged prophylaxis provides any benefit to patients with persistent echocardiographic findings.

Cardiac tamponade as a rare form of presentation of rheumatic carditis.

In this article the authors describe a clinical case of acute rheumatic fever (according to revised Jones criteria, American Heart Association [AHA], 1992) with cardiac tamponade, emphasizing this uncommon presentation. An adolescent patient with a clinical picture of cardiac tamponade was seen in the emergency department. Clinical progression and tests demonstrated rheumatic carditis with an initial manifestation of pericarditis with cardiac tamponade. This report aims to warn physicians about the diagnosis of rheumatic carditis in an unusual clinical presentation, in cases of cardiac tamponade, particularly in school-aged children and adolescents in countries with a high prevalence of rheumatic fever. The literature contains only two documented cases of cardiac tamponade related to acute rheumatic fever, and this case represents a third.