Treatment Options for Rheumatic Heart Disease

Rheumatic heart disease requires a comprehensive approach to management, primarily focusing on symptom relief and supportive care. In cases where patients experience acute pulmonary edema, nitrate medications are often recommended. These drugs help dilate the venous system, effectively reducing the heart's preload. It is generally advised to avoid vasodilators that primarily target small arteries, as they may not be suitable in this scenario.

Managing Atrial Fibrillation and Heart Rate

During an acute episode of pulmonary edema, if the patient also has atrial fibrillation, digoxin (Lanoxin) can be administered to slow the ventricular rate and alleviate symptoms such as palpitations. For patients who do not respond adequately to digoxin alone, additional medications like diltiazem or esmolol may be considered to better control heart rate. Patients with atrial fibrillation lasting less than one year and a left atrial diameter under 60 mm may be candidates for cardioversion—either through electrical means or medication. For those in whom cardioversion is not an option or has failed, beta-blockers, non-dihydropyridine calcium channel blockers, and digitalis preparations can be used to manage ventricular rate.

Preventing Thromboembolic Events

While controlling ventricular rate is crucial, it is equally important to address the risk of thromboembolism. Anticoagulation therapy is typically recommended, with warfarin being the preferred agent. The target international normalized ratio (INR) is usually maintained between 2.5 and 3.0 to ensure adequate protection against clot formation without increasing bleeding risk.

Addressing Severe Symptoms Like Hemoptysis

In situations where patients experience significant hemoptysis, immediate management includes placing the patient in an upright sitting position, administering sedatives, and using diuretics to reduce pulmonary artery pressure. Commonly used diuretics include torasemide and furosemide, which help alleviate fluid buildup and reduce strain on the cardiovascular system.

Preventive Strategies and Long-Term Care

In addition to acute symptom management, long-term preventive strategies are essential. Patients should be counseled on the importance of preventing recurrent rheumatic fever and the risk of infective endocarditis. Long-term, and in some cases lifelong, prophylaxis with benzathine penicillin G (1.2 million units administered intramuscularly once monthly) is typically recommended as a standard preventive measure in clinical practice.