Overview
Rheumatic heart disease is permanent damage to the valves of the heart. WHO states it results from damage caused by one or more episodes of rheumatic fever, which is the body’s own inflammatory reaction to a throat infection with group A streptococcus.
The chain is preventable at every link. A sore throat treated properly does not become rheumatic fever. Rheumatic fever treated and followed up does not usually become heart disease. WHO describes it as the most commonly acquired heart disease in people under 25.
Disease Summary
- Category
- Non-Communicable Disease
- Cause
- Damage to heart valves following rheumatic fever
- Transmission
- Not transmissible. The throat infection that starts it is
- Body System
- Cardiovascular System
- Preventable
- Yes
- Curable
- No
Symptoms
Common Symptoms
Rheumatic fever appears about one to five weeks after a strep throat. The heart damage it leaves behind may cause no symptoms for years.
Painful, Swollen Joints
During rheumatic fever, joints become hot and swollen, and the pain characteristically moves from one joint to another.
Fever
Fever accompanies the joint pains during an episode of rheumatic fever.
Chest Pain or Palpitations
Inflammation of the heart during rheumatic fever can cause chest discomfort and an awareness of the heartbeat.
Breathlessness on Exertion
As valve damage develops, breathlessness during activity is usually the first thing noticed.
Tiredness and Reduced Exercise Tolerance
Being unable to keep up with peers is often the earliest sign in a child.
Swollen Ankles
Fluid collecting in the legs indicates the heart is struggling and needs assessment.
Jerky, Uncontrolled Movements
An uncommon feature of rheumatic fever, appearing weeks to months later, with involuntary movements and emotional changes.
Skin Rash or Lumps Under the Skin
A distinctive rash and small painless lumps over the joints are recognised features of rheumatic fever.
Danger Signs
Seek urgent medical attention immediately if any of the following symptoms develop.
Breathlessness at Rest or When Lying Flat
Needing to sit up to breathe, or waking breathless at night, indicates the heart is failing and requires urgent care.
Chest Pain
Chest pain in someone with known valve disease needs same-day assessment.
Sudden Weakness or Difficulty Speaking
Damaged valves can lead to clots that cause a stroke. This is a medical emergency.
Prolonged Fever in Someone With Valve Disease
This can indicate infection of the heart valves, which is serious and needs urgent investigation.
Pregnancy With Known Valve Disease
WHO states that where the disease is common it is the principal heart disease seen in pregnant women, causing significant illness and death for both mother and baby. Specialist care is needed.
Diagnosis
Listening to the Heart
A new heart murmur in a child with fever and joint pains is often the finding that makes the diagnosis.
The Diagnostic Criteria for Rheumatic Fever
The diagnosis rests on a recognised combination of major features such as carditis, arthritis, the characteristic movements, rash and skin nodules, alongside minor features, plus evidence of a preceding strep infection.
Evidence of a Recent Strep Infection
Blood tests for antibodies against the bacterium show that a strep infection preceded the illness, which is required for the diagnosis.
Echocardiography
An ultrasound scan of the heart shows which valves are damaged and how severely. It can detect damage before any murmur is audible.
Electrical Tracing of the Heart
Shows disturbances of the heart rhythm and conduction that occur in rheumatic fever and in established valve disease.
Laboratory Tests
Throat Swab for Group A Streptococcus
Identifies the infection that starts the whole chain. Treating it properly is what prevents rheumatic fever.
Antibody Tests for Recent Strep Infection
Show that a strep infection occurred in the preceding weeks, which is required to diagnose rheumatic fever.
Inflammatory Markers
Raised levels support active inflammation and are used both to make the diagnosis and to follow the response to treatment.
Echocardiogram
The key test. It shows which valves are affected, how badly, and whether the heart muscle is coping.
Electrocardiogram
Detects rhythm disturbances, which are common in established valve disease and change treatment.
Treatment
Antibiotics to Clear the Strep Infection
Treating the throat infection properly prevents rheumatic fever. CDC states that rheumatic fever follows a group A strep infection, usually one to five weeks afterwards.
Long-Term Preventive Antibiotic Injections
The single most important treatment. Regular injections prevent further attacks of rheumatic fever, and each attack causes more valve damage. WHO’s 2024 guidelines cover this and how to help people keep to it.
Anti-Inflammatory Treatment
Reduces the joint pain and inflammation during an attack. WHO’s 2024 guidelines address the use of these medicines.
Heart Failure Treatment
Where valve damage has weakened the heart, medicines reduce the workload on it and control symptoms.
Valve Surgery
Repair or replacement of a badly damaged valve. Access to heart surgery is the main limitation in many of the countries where the disease is commonest.
Prevention
Treat sore throats properly in children
CDC states that rheumatic fever follows a group A strep infection. Recognising and treating strep throat is the first line of prevention.
Regular preventive injections after rheumatic fever
This prevents further attacks and is what stops mild valve damage becoming severe.
Keep a record and never miss an injection
WHO’s 2024 guidelines specifically address interventions to help people keep to long-term preventive treatment.
Screening for early disease
Ultrasound screening finds valve damage before symptoms appear, when preventive treatment still makes the most difference.
Reduce crowding and improve living conditions
Strep throat spreads by close contact, so crowded housing increases the number of infections that can start the chain.
Specialist care in pregnancy
WHO notes that where the disease is endemic it is the principal heart disease in pregnant women, so pre-pregnancy assessment matters.
Risk Factors
Children and Young People
WHO describes it as the most commonly acquired heart disease in people under age 25.
- Children aged roughly 5 to 15, the age at which rheumatic fever most often occurs
- Children who have already had one episode of rheumatic fever
- Children with untreated or repeatedly treated sore throats
- Young people who have stopped their preventive injections
Communities With Crowded Housing and Limited Health Access
WHO states the disease remains prevalent in sub-Saharan Africa, the Middle East, central and south Asia and the south Pacific.
- Households where several children share sleeping space
- Communities far from a clinic that can test and treat a sore throat
- Places where preventive penicillin is not reliably available
- WHO Regional Office for Africa reports that sub-Saharan Africa accounts for around 23% of cases worldwide
Pregnant Women With Valve Disease
WHO identifies this group explicitly.
- Pregnancy places substantial extra demand on a damaged heart
- WHO states it causes significant illness and death for both mother and baby where the disease is endemic
- Assessment before pregnancy allows planning
- Delivery needs specialist care
Complications
Heart Failure
Damaged valves make the heart work harder until it can no longer keep up, causing breathlessness and swelling.
Irregular Heart Rhythm
Valve disease commonly leads to an irregular rhythm, which itself raises the risk of stroke.
Stroke
Clots can form on damaged valves or in an irregularly beating heart and travel to the brain.
Infection of the Heart Valves
Damaged valves are vulnerable to infection, which is a serious illness needing prolonged treatment.
Complications in Pregnancy
WHO states that where the disease is endemic it causes significant illness and death for both mother and baby.
Premature Death
WHO reports approximately 360 000 deaths each year, mostly in young people who would otherwise have had decades of healthy life.
When to Seek Medical Care
A Sore Throat With Fever in a Child, in an Endemic Area
Particularly with swollen neck glands and no cough. Testing and treating it prevents the whole chain.
Painful, Swollen Joints With Fever in a Child
Especially if the pain moves from joint to joint. This needs assessment for rheumatic fever.
Breathlessness, Reduced Exercise Tolerance or Swollen Ankles
In anyone with a history of rheumatic fever, these suggest the valves are affected.
Sudden Weakness, Facial Droop or Difficulty Speaking
This is a stroke until proven otherwise and is an emergency.
If You Have Missed a Preventive Injection
Go back rather than giving up. Restarting is far better than stopping.
Prognosis
Prevention Works Completely
A properly treated strep throat does not cause rheumatic fever, and regular preventive injections after rheumatic fever prevent further attacks.
Established Valve Damage Does Not Reverse
Damage already done to a valve is permanent. Treatment aims to stop it getting worse and to manage its effects.
Surgery Can Transform Outcomes
Valve repair or replacement restores function, but access to heart surgery is limited in many of the countries where the disease is commonest.
It Affects People in Their Most Productive Years
WHO describes it as the most commonly acquired heart disease in people under 25, which is what makes its impact on families and economies so large.
Differential Diagnosis
Other Causes of Joint Pain in Children
Viral infections, juvenile arthritis and joint infection all cause painful swollen joints, and are separated by the pattern and by testing.
Congenital Heart Disease
Heart murmurs present from birth are separated from rheumatic damage by echocardiography and by the history.
Infection of the Heart Valves
Causes fever and murmurs, and is separated by blood cultures. It can also occur on top of rheumatic valve damage.
Other Causes of Heart Failure
High blood pressure, heart muscle disease and anaemia all cause breathlessness and swelling, and are separated by echocardiography.
Other Causes of Abnormal Movements
Several conditions cause involuntary movements in children, and the link to a recent strep infection is what points to rheumatic fever.
References
World Health Organization: Rheumatic heart disease
WHO fact sheet on cause, burden, prevention, treatment and the 2024 WHO guidelines.
CDC: About Rheumatic Fever
How rheumatic fever follows a group A strep infection, its symptoms and its consequences.
CDC: Diagnosing Acute Rheumatic Fever
The diagnostic criteria and the evidence of preceding strep infection required.
CDC: About Strep Throat
Recognising and treating the throat infection that starts the chain.
Frequently Asked Questions
How does a sore throat damage the heart?
Not directly. WHO states that rheumatic heart disease results from damage caused by rheumatic fever, which is the body’s own inflammatory reaction to a throat infection with group A streptococcus. CDC states this reaction appears about one to five weeks after the infection. The bacteria are not in the heart, the immune response is what causes the harm.
Can rheumatic heart disease be cured?
The valve damage cannot be reversed. What can be done is to prevent further attacks with regular preventive antibiotic injections, treat the effects on the heart, and repair or replace badly damaged valves surgically where that is available.
Why are the injections needed for so many years?
Because each further episode of rheumatic fever causes more valve damage, and people who have had it once are far more likely to have it again. Preventive injections given regularly for years are what stop mild damage becoming severe. WHO’s 2024 guidelines specifically address helping people keep to this treatment.
Does every sore throat need antibiotics?
No. Most sore throats are viral and do not need antibiotics. The point is to identify the ones caused by group A streptococcus and treat those, which is why testing matters in places where rheumatic fever occurs.
Is it safe to become pregnant with valve disease?
It needs planning. WHO states that where the disease is endemic it is the principal heart disease seen in pregnant women and causes significant illness and death for both mother and baby. Assessment before pregnancy and specialist care during it make a substantial difference.