The prognosis of acute rheumatic fever

Abstract

The clinical events of acute rheumatic fever have been correlated with the subsequent cardiac sequelae in 441 children and adolescents who were receiving continuous antimicrobial prophylaxis after rheumatic episodes that occurred during 1950–1957. The follow-up examinations, which extended for a mean of 7.8 years, were performed at monthly or bimonthly intervals in an outpatient epidemiologic research clinic, where special methods were used to improve the objectivity, precision, and standardization of the examining physicians' cardiac auscultation and roentgenographic interpretation. “Carditis” was defined clinically according to the presence or absence of significant cardiac murmurs, specified by rigorous criteria; “severe carditis” was manifested by significant cardiac enlargement or decompensation. The long-term results showed the following: 1. 1. The proportionate distribution and severity of carditic and noncarditic clinical features in the population was similar to that of a comparable population whose acute rheumatic episodes occurred during 1958–1960. 2. 2. All of the 181 patients who were initially free of carditis have remained free of rheumatic heart disease. 3. 3. Of the 260 patients with various forms of carditis initially, the evidence of cardiac damage has disappeared in 113, leaving only 147 patients with definite residual rheumatic heart disease. 4. 4. Of those 147 patients, 12 have died. All but one of these 12 patients had severe carditis in the antecedent acute rheumatic episode, and only one had later evidence of recurrent or persistent acute rheumatic inflammation. 5. 5. The disappearance of rheumatic heart disease was most likely to occur in patients who had: mild rather than severe carditis; a first rheumatic attack rather than a recurrence; systolic murmurs only rather than diastolic murmurs; murmurs of one valve rather than of two; and arthropathic manifestations rather than no joint symptoms. 6. 6. In the 271 patients whose acute rheumatic episodes were first attacks, the cardiac outcome depended on the presence and severity of carditis when treatment began, and was unrelated to the agent of treatment or to the promptness with which treatment was started after the onset of symptoms. 7. 7. Evidence of pericarditis was most common in patients with other manifestations of carditis and did not alone appear to influence prognosis. 8. 8. A prolonged P-R electrocardiographic interval occurred in about one third of all patients during the acute rheumatic episodes, regardless of the simultaneous presence or severity of carditis, and had no direct relationship to the ultimate cardiac state. These results confirm certain well-established concepts of clinical behavior in acute rheumatic fever, and contradict others. They indicate the importance of careful attention to clinical observation in recognizing the different subgroups of patients, with different cardiac prognosis, who constitute the complex, diverse spectrum of acute rheumatic fever.