How should I manage a patient with rheumatic heart disease who presents with new-onset heart failure symptoms?

When a patient with rheumatic heart disease (RHD) presents with new-onset symptoms of heart failure, the primary management involves urgent specialist assessment and symptomatic relief.

• Urgent Specialist Assessment and Referral: If heart failure is suspected based on symptoms such as breathlessness (especially when lying down or at rest), unexplained cough (particularly with frothy pink sputum), paroxysmal nocturnal dyspnoea, or palpitations, a senior clinician should review the woman's condition without delay NICE NG121. Signs like a persistent heart rate over 110 bpm, respiratory rate over 20 bpm, hypotension, oxygen saturation below 95% on air, elevated jugular venous pressure, or new heart sounds/crackles also suggest heart failure NICE NG121. Adults with a murmur and severe symptoms (angina or breathlessness on minimal exertion or at rest) thought to be related to valvular heart disease should be considered for urgent specialist assessment, including an echocardiogram, within two weeks NICE NG208. People with heart failure due to valve disease, including RHD, should be referred for specialist assessment and advice regarding follow-up NICE CKS. Referral to a specialist is also indicated for adults with moderate or severe valve disease of any type NICE NG208.
• Initial Symptomatic Management: If symptoms of fluid overload are present, a loop diuretic should be offered and titrated according to symptoms NICE CKS. The dose should be reviewed and adjusted after introducing other drug treatments NICE CKS. If symptoms are not relieved with maximal doses of diuretic, specialist advice should be sought NICE CKS.
• Pharmacological Considerations (Post-Specialist Assessment): Do not offer an angiotensin-converting enzyme (ACE) inhibitor if there is clinical suspicion of haemodynamically significant valve disease until the valve disease has been assessed by a specialist NICE CKS. Once assessed, an ACE inhibitor and a beta-blocker may be considered, with clinical judgment guiding which to start first NICE CKS. For adults with moderate to severe mitral stenosis and heart failure, a beta-blocker may be considered NICE NG208. If an ACE inhibitor is not tolerated, an angiotensin-II receptor antagonist (AIIRA) can be offered NICE CKS. If symptoms persist despite optimized standard care, further specialist advice should be sought NICE CKS. Dapagliflozin and empagliflozin are recommended by NICE for symptomatic chronic heart failure with preserved or mildly reduced ejection fraction, on the advice of a heart failure specialist NICE CKS.
• Holistic and Ongoing Care: Ensure that any drugs which may cause or worsen heart failure are reviewed and stopped if appropriate NICE CKS. Screen for depression and anxiety, and if depression co-exists with heart failure, treatment should consider potential risks and benefits of drug treatment NICE CKS. If suitable and the heart failure is stable, the person should be offered referral to a supervised exercise-based group rehabilitation programme that includes psychological and education-based components NICE CKS. Ensure the person is offered an annual influenza vaccine and a once-only pneumococcal vaccination NICE CKS. Provide general information about heart failure and its management, including self-care advice NICE CKS. Assess the person's nutritional status; consider dietetic referral for BMI under 18.5 kg/m² or advice on healthy weight for BMI over 30 kg/m² NICE CKS. Discuss advance care planning and advance decisions at an early stage of the disease, if appropriate NICE CKS. Manage any comorbidities such as atrial fibrillation, hypertension, or diabetes NICE CKS. For women of child-bearing age, provide advice about contraception and pregnancy; if pregnancy is considered or occurs, specialist advice should be sought, and care should be shared between a cardiologist and obstetrician NICE CKS,NICE NG208. Contemporary diagnosis and management of rheumatic heart disease are further detailed in scientific statements from organizations like the American Heart Association (Kumar et al. 2020).