How should I approach the management of a patient with a heart murmur and a history of rheumatic fever?

Approach to managing a patient with a heart murmur and a history of rheumatic fever:

• Consider an echocardiogram to assess for valve disease, as rheumatic fever commonly causes valvular damage, especially mitral stenosis or regurgitation. The presence of a murmur and history of rheumatic fever strongly suggests valve pathology requiring imaging to define severity and guide management ¹.
• If the patient has symptoms such as breathlessness, angina, peripheral oedema, or an abnormal ECG, offer an echocardiogram promptly to evaluate valve function and cardiac status ¹.
• Refer urgently (within 2 weeks) for specialist assessment including echocardiography if the patient has a systolic murmur with exertional syncope or severe symptoms thought to be related to valve disease ¹.
• After echocardiography, refer to a specialist if moderate or severe valve disease is identified, or if the patient has bicuspid aortic valve disease of any severity (less relevant here but important for comprehensive care) ¹.
• For rheumatic severe mitral stenosis, consider transcatheter valvotomy if the valve anatomy is suitable; if not, offer surgical mitral valve replacement ¹.
• Manage heart failure symptoms pharmacologically, considering beta-blockers in moderate to severe mitral stenosis with heart failure, and refer to chronic heart failure guidelines if left ventricular dysfunction is present ¹.
• Provide patient information and involve them in decision-making about their care, including implications for pregnancy if relevant ¹.