Rheumatic Heart Disease with Complication of

Atrial Fibrillation : A Case Report

Samudra Andi Yusuf1, Irma Vitriani2, I Gusti Ayu
Suryawati3
1
General Practitioner at Bangli General Hospital, Bali, Indonesia
2
Internship Doctor at Bangli General Hospital, Bali, Indonesia
3
Cardiologist at Bangli General Hospital, Bangli, Bali, Indonesia

Introduction : Rheumatic heart disease (RHD) is the most common acquired disease for
patients aged under 25 years old. It was reported that more than 300.000 patients died as a
result of RHD (around 2% of the total cardiovascular deaths) with the highest distribution
pattern in East Asia and Southeast Asia. This disease are correlated with crowded population
density, poor sanitation and several factors that related with low healthcare level.1
Case Illustration : A 46 years old female presented to cardiology department with chief
complaint dyspnea since one week ago. Dyspnea appear upon exertion along with
paroxysmal nocturnal dyspnea and orthopnea. Moreover, sometimes her heart are also
pounding and experienced fatigue when performing daily activities. She had past medical
history of recurrent upper respiratory tract infection, polyarthritis and fever at the age of 15
years old, but never going to the hospital to get any treatment. Upon physical examination,
heart rate 79 bpm irregular, respiration 28x/minutes while other vital sign are normal. Jugular
venous pressure was elevated (5±3 cm H2O). Auscultation of the lungs and heart shows
irregular S1-S2, high pitched pansystolic murmur at mitral and tricuspid valve. There is also
mid-to-late diastolic low pitched murmur heard at mitral valve and it is preceded by an
opening snap. Crackles are present at bases of the both lungs. Interpretation of ECG, chest x-
ray and echocardiography were on the pictures below. Working diagnosis for this patient
were severe mitral stenosis et causa rheumatic heart disease, congestive heart failure NYHA
functional class II and atrial fibrillation normoventricular rate. This patient was treated as an
outpatient and received several medication include warfarin 0-0-2 mg, furosemid 1x40 mg,
spironolacton 1x25 mg and digoxin 1x0,25 mg.

Figure 1. Atrial fibrillation rhythm, HR 80x/minutes, right axis deviation, right ventricular
hypertrophy
 Figure 2. Cardiomegaly (LAE, RVH) with signs
of pulmonary congestion, interstitial lung
oedema and atherosclerosis aortae

Figure 3. Dilatation right & left atrium, Ejection Fraction 59,8%, Reduced diastolic left ventricular
function, Global Normokinetic, Severe MS (RHD), Mild MR, Moderate TR, Sac (-)

Discussion : Rheumatic heart disease is a sequele of acute rheumatic fever that cause damage
to one or more heart valves. From patient past medical history, it is suspected that this patient
get acute rheumatic fever at the age of 15 years old because there are 3% probabilities of the
population that develop autoimmune process after recurrent episodes of pharyngitis caused
by streptococcus beta hemolitikus grup A.2 Presence of murmur based on physical
examination increase the suspicion of valvular heart disease caused by rheumatic heart
disease. Echocardiography results which are matched with WHF criteria on rheumatic heart
disease confirm the diagnosis.3 Atrial fibrillation reveals from the ECG result was common
complication of mitral stenosis.4 This patient received warfarin as a prophylaxis for ischemic
stroke.5 Furosemid and spironolakton were being given to relieve signs and symptoms of
congestion. Digoxin was given orally as a rhythm control for atrial fibrillation. Secondary
prophylaxis are not needed for this patient as her age was already 46 years old.5
Conclusion : Rheumatic heart disease remains a significant problem of cardiovascular
disease particularly in East Asia and Southeast Asia. This disease are related with low
healthcare level. A continuous improvement especially in the prevention method are
indispensable to eradicate this disease in the future.
Keywords : Rheumatic Heart Disease, Atrial Fibrillation, Congestive Heart Failure,
Rheumatic Fever
References :
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National Burden of Rheumatic Heart Disease, 1990-2015. N Eng J Med.2017 Aug 24;377(8):713-727.
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Rheumatic Fever and rheumatic heart disease: report of a WHO Expert Consultation, Geneva, 29 Oct
– 1 Nov 2001. (WHO Technical Report Series No.923).
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echocardiographic diagnosis of rheumatic heart disease – An evidence based guideline. Nat Rev
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6th ed.Lippincott Williams & Wilkins;2016. Pg.192-210.
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Atrium. Perhimpunan Dokter Spesialis Kardiovaskular Indonesia (PERKI). 2014. Indonesia.