Page 62 - JSOM Summer 2025

tricuspid or pulmonic valves are less frequently affected in BOX 1 2012 World Federation Criteria for Echocardiographic
RHD, and the aortic valve is only affected in <2% of cases. 11 Diagnosis of RHD
For Age < 20 Years
Most patients who develop RHD will present with symptoms Definite RHD (either A, B, C, or D):
associated with mitral valve dysfunction, including shortness of A) Pathological MR and at least 2 morphologic features of RHD
breath, palpitations, fatigue, decreased exercise tolerance, and of the MV
4
syncope or near-syncope. Worsening MS may cause increased B) MS gradient >4 mmHg
left atrial pressures and lead to symptoms of heart failure such C) Pathological AR and at least 2 morphologic features of RHD of
as orthopnea, paroxysmal nocturnal dyspnea, dysphagia, and the AV
dyspnea on exertion. Severe valvular disease may also pose D) Borderline disease of both AV and MV
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risk for exertional syncope and sudden cardiac death. Phys-
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ical exam may reveal murmurs, such as a mid-diastolic rum- Borderline RHD (either A, B, or C):

bling murmur heard in MS or a systolic murmur radiating to A) At least two morphological features of RHD of the MV without
pathological MR or MS
the axilla heard in MR. ECG changes are non-specific but
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may include p-wave changes, right-axis deviation, right ven- B) Pathological MR
tricular hypertrophy, or arrhythmias such as atrial fibrillation C) Pathological AR
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in those with more severe mitral valve damage. Auscultated Normal echocardiographic findings (either A, B, C, or D):
murmurs should be investigated with TTE which may reveal A) Physiologic MR that does not meet all four Doppler
valvular thickening, deformity, or decreased leaflet mobility. echocardiographic criteria
Referrals to cardiology and potentially cardiothoracic surgery B) Physiologic AR that does not meet all four Doppler
should be placed. echocardiographic criteria
C) Isolated morphological feature of RHD of the MV, without
pathological MS or MR
Once congenital, acquired, or degenerative heart disease as an
underlying cause are excluded by cardiology, a presumed di- D) Morphological feature of RHD of the AV, without pathological
AS or AR
agnosis of RHD can be formally made using the 2012 World
Health Federation criteria (Box 1). The criteria are based on For Age > 20 Years
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age and evidence of echocardiographic findings. For those Definite RHD (either A, B, C, or D):
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under the age of 20 years, definite RHD criteria can be met by A) Pathological MR and at least two morphologic features of RHD
having both pathologic and morphologic RHD features within of the MV
the mitral or aortic valves, or an MS gradient >4 mmHg. B) MS gradient >4 mmHg
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Borderline RHD criteria are met by having at least two mor- C) Pathological AR and at least 2 morphologic features of RHD of
phologic features in the mitral valve with pathologic findings, the AV
or pathologic findings alone. For those over the age of 20 D) Pathological AR and at least 2 morphologic features of RHD of
years, definite RHD is met in the same manner; however, there the MV
are no borderline criteria for this age group. RHD = rheumatic heart disease; MR = mitral regurgitation; MV =
mitral valve; MS = mitral stenosis; AV = aortic valve; AR = aortic
regurgitation; AS = aortic stenosis.
Once identified, initial management may begin with secondary
antibiotic prophylaxis with a prolonged course of penicillin
to eradicate the GAS infection, prevent disease progression, RHD-related heart failure from 1990 to 2015. Once thought
5
and decrease morbidity. Exercise restrictions and other life- to be a declining disease process in the United States and only
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style modifications may be implemented based on disease se- a result of foreign exposure, RHD has had an increase in
verity. Initial medical management for MS may be offered to age-adjusted mortality rates from 2017 to 2020 with projec-
control consequences of long-standing stenosis or regurgita- tions for a surge in RHD-associated complications in the com-
3
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tion. Heart failure may be managed through goal-directed ing decade. Additionally, in a 10-year multicenter review by
medical therapy with diuretics, angiotensin-converting enzyme de Loizaga et al., 87% of diagnosed RHD cases had no travel
inhibition (ACE-i) or angiotensin II receptor blocker (ARBs), to endemic regions, indicating a continued domestic burden
beta-blockers, or mineralocorticoid receptor antagonists. 4,11,15 of ARF and RHD. Many patients and providers alike are un-
2
Atrial fibrillation can lead to thromboembolism, stroke, or aware of the consequences of untreated strep throat infections,
worsening heart failure and should be managed with calcium the overall disease burden, and increasing mortality rates. This
channel blockers, beta-blockers, or digoxin with consideration case emphasizes the importance of primary screening and pre-
for anti-coagulation. 4,15 Definitive management for severe dis- vention in the U.S. for GAS infections, but also the need for
ease may be achieved through percutaneous or surgical inter- increased echocardiographic evaluations and secondary pro-
vention via valvular repair or replacement. 4,15 Valvular repair phylaxis when ARF is suspected in order to prevent progres-
can be performed via balloon mitral valvuloplasty or mitral sion to RHD.
commissurotomy and does not require definitive anticoagu-
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lation. Valve replacements can be bioprosthetic or mechan- The underlying physiologic effects and treatment of RHD
ical, though in contrast, mechanical valves require lifelong present a risk of debilitation for military servicemembers, es-
anticoagulation. 15 pecially SOF servicemembers. While not specifically addressed
in the Army Regulation for Standards of Medical Fitness, AR
RHD is a leading cause of preventable death and disability 40-501, consequences of RHD such as valvular dysfunction,
in children and young adults worldwide. Numerous recent valvular heart disease, atrial fibrillation, and long-term use of
1
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global health initiations have increased primary screening and anticoagulants do not meet standards for military service.
prevention, though RHD remains a significant burden across Therefore, a Soldier with underlying valvular disease would be
developing nations globally with an increased prevalence of placed on a permanent profile and be referred to the Disability
60 | JSOM Volume 25, Edition 2 / Summer 2025