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Treatment Choice in Acute Rheumatic Carditis

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Treatment Choice in Acute Rheumatic Carditis Arch Dis Child: first published as 10.1136/adc.59.5.410 on 1 May 1984. Downloaded from Archives of Disease in Childhood, 1984, 59, 410-413 Treatment choice in acute rheumatic carditis D G HUMAN, I D HILL, AND C B FRASER Department of Paediatrics and Child Health, University of Cape Town, Red Cross War Memorial Children's Hospital, Cape Town, South Africa. SUMMARY A trial was conducted using sequential analysis by pairs to compare the efficacy of corticosteroids and salicylates in the treatment of acute rheumatic carditis. The results show a significantly favourable effect of steroid treatment both in clinical response and in reduction of the erythrocyte sedimentation rate. In addition, patients receiving steroids usually had a shorter hospital stay. The use of steroids in acute rheumatic fever with carditis is recommended. While the decline in rheumatic fever and rheumatic Table 1 Jones' criteria (revised) heart disease is a phenomenon of the developed world, in Africa and Asia the disease is still an Major manifestations Minor manifestations important cause of mortality and morbidity.t The Carditis Clinical place of corticosteroids in the treatment of acute Polyarthritis Fever Chorea Arthralgia rheumatic carditis remains unclear despite more Erythema marginatum Previous rheumatic fever or than 20 years of use in clinical practice. Most Subcutaneous nodules rheumatic heart disease authorities now endorse the use of steroids in Laboratory Acute phase reaction patients with moderate to severe carditis,2 4 Erythrocyte sedimentation rate although some still claim that steroids have no place C reactive protein Leukocytosis in the treatment of acute rheumatic carditis.5 This Prolonged PR interval study was designed to compare the efficacy of PLUS steroids and salicylates in the management of acute Supporting evidence of preceding stroptococcal infection http://adc.bmj.com/ rheumatic carditis. The presence of two major criteria, or of one major and two minor criteria, indicates a high probability of rheumatic fever. Patients and methods Table 2 Features of rheumatic carditis All children presenting to the Red Cross War Memorial Children's Hospital with features of acute (I) Murmurs (it) Signiticint apical svstolic murmur. apical rheumatic fever were referred to a member of the diastolic murmur. or hasal diastolic murmur without a previous historv of rheumatic tevcr cardiology unit. Those patients fulfilling the follow- on October 1, 2021 by guest. Protected copyright. ing criteria were included in the study: (b) Change in the ch,ir,ictcr of a murmur. or dcvelopmcnt of a new murmur with a rheumatic fever as prcvious historv of rhcumatic fcver (1) The presence of acute (2) Cardiomegaly defined by the modified Jones' criteria6 (Table 1). (3) Pericarditis (2) Evidence of acute carditis (Table 2). (4) Congestive hcart failurc (3) No steroids or salicylates given in the preced- two weeks. ing gallop rhythm, considerably raised venous pressure, The study began in June 1981 and was completed clinically obvious cardiomegaly) two points. Valvu- in September 1982. lar disease was allocated one point for a typical A clinical scoring system was used to grade the organic murmur of grade 3/6 or less, and two points severity of cardiac disease at the time of hospital if a 'thrill' was present. The total number of valves admission. Congestive cardiac failure of a mild affected was also added to the score. A pericardial degree (that is, audible gallop rhythm, raised venous friction rub was allocated two points if present. In pressure, or hepatic enlargement of less than 3 cm this way patients could be matched according to and minimal cardiac enlargement) was allocated one their clinical score and were assigned to one of three point and more severe failure (that is, palpable groups. Group 1 comprised those with moderate 410 Arch Dis Child: first published as 10.1136/adc.59.5.410 on 1 May 1984. Downloaded from Treatrnent choice in acute rheumatic carditis 411 disease (score 1 to 5), group 2 those with severe Results disease (score 6 to 10), and group 3 those with life threatening carditis (score 11 to 16). All the patients A total of 24 patients were studied (12 pairs) 22 of had evidence of an affected mitral valve, and most whom had moderate disease and two severe disease. had had symptoms (chest pain, dyspnoea, lethargy) There were no cases of life threatening carditis for two weeks or less. Patients in each group were during the 12 months of the survey. Individual alternatively assigned to treatment with either ster- details of the patients are shown in Table 3. oids (prednisone 3 mg/kg/day for 10 days and then a In the method of sequential analysis by pairs each reducing dosage for a further 10 days) or salicylates patient receiving steroids was compared directly (soluble aspirin 100 mg/kg/day for 20 days). All with a patient receiving salicylates, the pair groups patients received oral penicillin 250 mg 6 hourly for having been decided at the time of admission to the 10 days with subsequent intramuscular penicillin for trial. There was noticeable preference for steroid long term prophylaxis, while digoxin and diuretics treatment 10 pairs showing a more rapid clinical were used when indicated. response by at least five days, and two pairs showing The patients were cared for in general paediatric equally rapid responses. In no case was the response wards and were regularly assessed by one of the more rapid with salicylates and this result is statisti- cardiologists. Clinical response to treatment was cally significant (P<0-05). The response of the identified by a fall in the sleeping pulse to below 80 erythrocyte sedimentation rate showed a similar beats/minute and a decline of at least one point in preference for steroid treatment; 9 pairs showing a the clinical score. The erythrocyte sedimentation fall to less than 30 mm in the first hour at least five rate (Westergren method) was monitored twice days earlier, with two pairs showing equally rapid weekly and a value below 30 mm in the first hour responses and the remaining pair having a pro- was accepted as a response to treatment. The longed response time. In no case was the response number of days taken to achieve clinical response to more rapid with salicylate, and this result was also treatment, the time for the erythrocyte sedimenta- significant at the P<0-05 level. tion rate to return to normal, and the total length of The duration of hospital stay was similar in four stay in hospital were recorded for each patient. patient pairs who received salicylates or steroids Each pair of patients was compared for the time with good response. In the 8 patients who failed to taken to achieve a clinical response, the time taken respond to the initial salicylate treatment steroids for the erythrocyte sedimentation rate to fall below were used subsequently and their hospital stay 30 mm in the first hour, and the total duration of reflects the therapeutic effect of both regimens. Five stay in hospital. The results were assessed using the patients who received steroids as initial treatment http://adc.bmj.com/ method of sequential analysis by pairs.7 had a shorter hospital stay by at least five days and Table 3 Details of 12 pairs of patients with acute rheumatic carditis Salicylate treatment Steroid treatment On admission Treatment On admission Treatment on October 1, 2021 by guest. Protected copyright. Clinical ESR Other Clinical ESR Hospital Clinical ESR Other Response ESR Hospital score signs response response stay score signs (days) response stay (days) (days) (days) (days) (davs) Group I Pair 1 89 Chorea, NR NR 3(0 11() 31) 42 nodules Pair 2 135 Arthritis I I NR 37 71) I In 39 Pair 3 60 - NR NR 49 3 116 Arthritis 16 7 41 Pair 4 43 121 - NR NR 57 87 _ 8Is 16 29 Pair 5 1t1 14 2'4 4 91 _ 13 14 23 Pair 6 4 78 _ 2' NR 38 It)) _ 9 9 33 Pair 7 3 130 - NR NR 73 4(0 - 21) 6 Pair 8 4 129 - NR NR 611 4 91) Chorca S 6 295 Pair 9 4 120 Arthritis NR NR 9(1 - 9) 9 -23 Pair 1() 4 S(1 _ 21 12 811 Pvrcxila IS I() Pair 11 120) Arthritis I() NR 47 15() Arthritis 14 14 44 Group 11 Pair 1 8 44 NR NR 75 7 9(1 14 11) 4, NR= no response; ESR erythrocyte sedimentation rate in I hour. Subsequently received steroid treatment. Arch Dis Child: first published as 10.1136/adc.59.5.410 on 1 May 1984. Downloaded from 412 Human Hill, and Fraser in three pairs the stay was similar. There was benefit from steroid treatmentl'o and there is no therefore a trend towards a shorter hospital stay in evidence that patients treated with steroids fare the steroid treated pairs but a significant difference worse than others. cannot be shown probably because of the introduc- An increased surgical risk for valve replacement tion of steroids to some of those initially treated with after steroid treatment has been cited as a contra- salicylate. indication to their use.5 The operative mortality for mitral valve replacement at our hospital is less than Discussion 5% and most patients had rheumatic heart disease. " The results obtained for emergency valve replace- The accurate assessment of a clinical response to ment in acute rheumatic fever without the prior use treatment is difficult. To obtain objectivity of steroids show no improvement on these figures. documentation of the sleeping pulse rate, the (Kinsley RH. Annual Report 1982, Division of erythrocyte sedimentation rate, and a clinical scor- Cardio-thoracic Surgery, University of the ing system were used at the time of hospital Witwatersrand).
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