What are the recommended follow-up protocols for patients with rheumatic heart disease to monitor for cardiac complications?

For patients with rheumatic heart disease, follow-up protocols primarily focus on monitoring for cardiac complications, often aligning with guidelines for heart valve disease and chronic heart failure.

• Initial Specialist Referral and Assessment:
• Adults with moderate or severe valve disease of any type, or bicuspid aortic valve disease of any severity (including mild), should be offered referral to a specialist ⁵.
• People with heart failure due to valve disease should be referred for specialist assessment and advice regarding follow-up ¹.
• Pregnant women or women considering pregnancy with moderate or severe valve disease, bicuspid aortic valve disease (any severity with associated aortopathy), or a prosthetic valve should be referred to a cardiologist with expertise in pregnant women's care, regardless of symptoms ⁵. Specialist care should be shared between a cardiologist and obstetrician if pregnancy is considered or occurs ¹,².
• General Follow-up and Monitoring for Heart Failure (Common Complication):
• All people with chronic heart failure require regular follow-up and monitoring ¹,².
• Heart failure care should be delivered by a dedicated multidisciplinary team, which may include a dedicated heart failure nurse and a pharmacist ¹.
• The frequency of follow-up needs to be individualized based on symptom severity, stability, treatment, and comorbidities ¹.
• The follow-up interval should be short (days to 2 weeks) if the person's clinical condition or drugs have changed ¹.
• For stable conditions, follow-up should occur at least every 6 months ¹. This includes a clinical assessment, medication review, and assessment of renal function ¹,².
• Clinical Assessment and Monitoring:
• Assess functional capacity (e.g., using New York Heart Association classification), fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status, and nutritional status ¹,².
• Ask about palpitations, shortness of breath, presence of oedema, and syncopal/presynopal symptoms ¹.
• If syncope or presyncope occurs (unless clearly due to postural hypotension), refer to a cardiologist ¹.
• If an arrhythmia is suspected, arrange a 12-lead ECG or 24-hour ECG monitoring ¹.
• Assess fluid status by checking for changes in body weight, oedema (abdomen, sacrum, genitalia, ankles), raised jugular venous pressure, fine lung crepitations, hepatomegaly, and postural drop in blood pressure ¹.
• Monitor serum urea, electrolytes, and estimated glomerular filtration rate (eGFR) every 6 months ¹.
• Consider monitoring N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) levels in people less than 75 years of age to guide optimum drug treatment, especially for those with a higher baseline NT-pro-BNP level (greater than 2114 pg/mL) ¹.
• Medication Review:
• Review the person's medications, including over-the-counter preparations, and ask about possible adverse effects ¹,².
• For people taking amiodarone, offer liver and thyroid function tests and a review of side effects as part of their routine 6-monthly clinical review ².
• For people with heart failure and atrial fibrillation, follow the recommendations on anticoagulation in the NICE guideline on atrial fibrillation ². In people with heart failure in sinus rhythm, anticoagulation should be considered for those with a history of thromboembolism, left ventricular aneurysm, or intracardiac thrombus ². Be aware of the effects of impaired renal and liver function on anticoagulant therapies ².
• Preventive Measures and Holistic Care:
• Offer an annual influenza vaccine and a once-only pneumococcal vaccination ¹,².
• Screen for depression and anxiety ¹. Reassess psychological status once the physical condition has stabilized if depression is likely to have been precipitated by heart failure symptoms ¹.
• If suitable, ensure the person has been offered referral to a supervised exercise-based group rehabilitation programme for people with heart failure, which should include psychological and education-based components ¹.
• Assess nutritional status; consider dietetic referral if BMI is under 18.5 kg/m2, or give advice on healthy weight if BMI is over 30 kg/m2 ¹.
• Provide general information about heart failure and its management, including self-care advice ¹. Ensure sources of information and advice have been given to the person and their carers/family ¹.
• Offer a discussion about advance care planning and advance decisions, if appropriate, at an early stage of the disease ¹.