Clinical Evaluation and Diagnosis of Rheumatic Heart Disease


Until recently, the diagnosis and evaluation of rheumatic heart disease (RHD) was purely clinical in resource-poor settings where RHD has remained endemic. The advent of portable echocardiographic technology, however, now means that this valuable diagnostic tool is more widely available in resource-poor settings and in remote locations, thus transforming the diagnosis of both acute rheumatic fever (ARF) and RHD. In 2012, the first evidence-based echocardiographic guidelines were published to facilitate early diagnosis of mild RHD in individuals without a previous history of ARF. This was followed by revision of the Jones criteria in 2015 to include echocardiographic findings in the diagnosis of ARF. The most common manifestation of RHD in adults is multivalve and mixed valve disease. Current international guidelines focus on the evaluation of advanced single valve disease with either regurgitation or stenosis as the dominant pathology. A knowledge gap exists regarding the evaluation of multivalve and mixed valve diseases that characterize chronic RHD across the age spectrum.

A detailed review of the pathogenesis of ARF and RHD is presented in Chapter 2 . RHD is the only significant long-term sequela of ARF and predominantly affects the left-sided cardiac valves. Approximately 60% of patients who experience at least one episode of ARF will develop RHD. Although acute rheumatic valvulitis is often reversible, severe single or repeated episodes of ARF often lead to permanent scarring and chronic valvular dysfunction known as chronic RHD. Myocardial impairment and dilatation occur only in the setting of severe valve disease, and recovery can be expected if timely cardiosurgical correction of valvular dysfunction takes place. The initial or recurrent episode of ARF may lead to a prolonged phase of inflammation and requires a long period of rest and recovery. The pericardial effusion seen during the acute phase of ARF usually resolves with no long-term sequelae (see Chapter 3 for a more complete discussion of the clinical features of ARF).

Epidemiology of Rheumatic Heart Disease

In 2015, an estimated 33.4 million people worldwide had RHD, resulting in 319,400 deaths and 10.5 million disability-adjusted life-years lost per annum. Today, RHD predominantly affects those young people who live in marginalized communities or resource-poor settings. Many affected populations live in rural and remote regions, some distance from diagnostic and specialist services.

In childhood, by far the most common lesion in RHD is isolated mitral regurgitation ( Fig. 5.1 ). By adolescence and young adulthood, mixed multivalve disease involving both the aortic and mitral valves becomes the most common manifestation ( Fig. 5.1 ). Isolated aortic valve disease occurs in children but by adulthood it is rare, being more often associated with multivalve pathology ( Fig. 5.1 ). Pure mitral stenosis can occur as young as 10 years old but it is more common during the third and fourth decades of life. Chronic RHD is more common in women than men across all ages with unrecognized RHD affecting many women during their childbearing years leading to preventable morbidity and mortality for both mother and child ( Fig. 5.2 ).

Fig. 5.1

The pattern of native rheumatic valve disease in 2475 children and adults with no percutaneous or surgical intervention. MS, mitral stenosis; MR, mitral regurgitation; MMVD, mixed mitral valve disease; AVD, aortic valve disease; MAVD, mixed aortic valve disease; MMAVD, mixed mitral and aortic valve disease.

Reproduced with permission from Zühlke et al.

Fig. 5.2

Age and gender distribution of 3339 children and adults with rheumatic heart disease.

Reproduced with permission from Zühlke et al.

Diagnostic Criteria for Rheumatic Heart Disease

The diagnosis of RHD often occurs late and usually because of complications of the illness, including heart failure (HF), infective endocarditis, arrhythmias, stroke, pregnancy-related complications, or sudden death. A long latent phase of asymptomatic valvular heart disease, often without any preceding history or symptoms of ARF, is the most common scenario. The Global Rheumatic Heart Disease Registry study (REMEDY) showed that the proportion of patients with RHD who had a previous history of ARF is 22.3% in low-income countries, 44.3% in lower-middle-income countries, and 59% of upper-middle-income countries. Low public awareness of ARF and limited access to primary healthcare and diagnostic modalities are likely reasons for this disparity. Additionally, the current diagnostic guidelines may not be sufficiently sensitive to detect ARF in some high-risk populations.

The 2012 World Heart Federation (WHF) diagnostic criteria were developed by multinational collaboration to allow for standardized diagnosis of RHD with a focus on mild RHD in high-risk populations in individuals without a prior history of ARF ( Table 5.1 ). See Chapter 13 for discussions on RHD screening. The WHF definitions for pathologic aortic and mitral regurgitation have been adopted by the Jones criteria writing group to diagnose acute valvulitis in the setting of ARF. The diagnosis of ARF is discussed in Chapter 3 . Patients who present with ARF may have acute or “acute-on-chronic” RHD. This chapter explores the diagnosis of established chronic RHD.

Table 5.1

2012 World Heart Federation Criteria for the Echocardiographic Diagnosis of Rheumatic Heart Disease.

Reproduced from Remenyi et al.

Echocardiographic criteria for individuals aged ≤20 years
Definite RHD (either A, B, C, or D):

  • A)

    Pathological MR and at least two morphologic features of RHD of the MV

  • B)

    MS mean gradient ≥4 mmHg a

  • C)

    Pathological AR and at least two morphologic features of RHD of the AV b

  • D)

    Borderline disease of both the aortic and mitral valves c

Borderline RHD (either A, B, or C):

  • A)

    At least two morphological features of RHD of the MV without pathological MR or MS

  • B)

    Pathological MR

  • C)

    Pathological AR

Echocardiographic criteria for individuals aged >20 years
Definite RHD (either A, B, C, or D):

  • A)

    Pathological MR and at least two morphological features of RHD of the MV

  • B)

    MS mean gradient ≥4 mmHg a

  • C)

    Pathological AR and at least two morphological features of RHD of the AV, only in individuals aged <35 years b

  • D)

    Pathological AR and at least two morphological features of RHD of the MV

Echocardiographic criteria for pathological regurgitation (all four Doppler criteria must be met)
Pathological MR Pathological AR

  • 1.

    Seen in two views

  • 2.

    In at least one view, jet length ≥2 cm d

  • 3.

    Velocity ≥3 m/s for one complete envelope

  • 4.

    Pan-systolic jet in at least one envelope

  • 1.

    Seen in two views

  • 2.

    In at least one view, jet length ≥1 cm d

  • 3.

    Peak velocity ≥3 m/s in early diastole

  • 4.

    Pan-diastolic jet in at least one envelope

Morphological features of RHD
Mitral Valve Aortic Valve

  • 1.

    AMVL thickening e ≥3mm (age-specific) f

  • 2.

    Chordal thickening

  • 3.

    Restricted leaflet motion g

  • 4.

    Excessive leaflet tip motion during systole h

  • 1.

    Irregular or focal thickening i

  • 2.

    Coaptation defect

  • 3.

    Restricted leaflet motion

  • 4.


RHD, rheumatic heart disease; MV, mitral valve; AV, aortic valve; MR, mitral regurgitation; MS, mitral stenosis; AR, aortic regurgitation; AMVL, anterior mitral valve leaflet.

a Congenital MV anomalies must be excluded. Furthermore, inflow obstruction due to nonrheumatic mitral annular calcification must be excluded in adults.

b Bicuspid AV, dilated aortic root, and hypertension must be excluded.

c Combined AR and MR in high prevalence regions and in the absence of congenital heart disease is regarded as rheumatic.

d A regurgitant jet length should be measured from the vena contracta to the last pixel of regurgitant color (blue or red).

e AMVL thickness should be measured during diastole at full excursion. Measurement should be taken at the thickest portion of the leaflet, including focal thickening, beading, and nodularity. Measurement should be performed on a frame with maximal separation of chordae from the leaflet tissue. Valve thickness can only be assessed if the images were acquired at optimal gain settings without harmonics and with a frequency of >2.0 MHz.

f Abnormal thickening of the AMVL is age-specific and defined as follows: ≥3 mm for individuals aged ≤20 years; ≥4 mm for individuals aged 21-40 years; and ≥5 mm for individuals aged >40 years. Valve thickness measurements obtained using harmonic imaging should be cautiously interpreted and a thickness up to 4 mm should be considered normal in those aged ≤20 years.

g Restricted leaflet motion of either the anterior or the posterior MV leaflet is usually the result of chordal shortening or fusion, commissural fusion, or leaflet thickening.

h Excessive leaflet tip motion is the result of elongation of the primary chords and is defined as displacement of the tip or edge of an involved leaflet towards the left atrium, resulting in abnormal coaptation and regurgitation. Excessive leaflet tip motion does not need to meet the standard echocardiographic definition of MV prolapse disease, as that refers to a different disease process. This feature applies to only those <35 years of age. In the presence of a flail MV leaflet in the young (<20 years of age), this single morphologic feature is sufficient to meet the morphologic criteria for RHD (that is, where the criteria state “at least two morphologic features of RHD of the MV” a flail leaflet in a person <20 years of age is sufficient).

i In the parasternal short-axis view, the right and noncoronary aortic cusp closure line often appears echogenic (thickened) in healthy individuals and this should be considered as normal.

Diagnosis of Chronic Rheumatic Heart Disease in Individuals with a History of Acute Rheumatic Fever

In individuals with a confirmed diagnosis of ARF, and once acute inflammation has subsided after weeks to months, as determined by normalization of inflammatory markers, the persistence of pathologic regurgitation of the mitral and/or aortic valves on echocardiography (see Table 5.1 ) is pathognomonic for chronic RHD. In circumstances where echocardiography is not available, one must rely on clinical acumen and the persistence of a mitral and/or aortic regurgitant murmur to confirm the diagnosis of chronic RHD.

Diagnosis of Rheumatic Heart Disease in Individuals Without a History of Acute Rheumatic Fever

Even after screening questions on history, practice shows that most patients in the world are diagnosed with RHD without any previous history of ARF. Reasons for suspecting RHD and initiating a referral for clinical assessment and/or echocardiography may include the following: pathological murmur, exercise-induced chest pain, shortness of breath, HF, syncope, palpitations, atrial fibrillation, or stroke.

For the millions of young people in the world who already have established RHD, their best and most tangible hope for a longer and healthier life is to have their RHD detected at a stage when secondary prophylaxis has the greatest chance of modifying disease outcomes. The 2012 WHF standardized echocardiographic criteria were developed with the aim of achieving rapid and consistent differentiation of mild RHD from normal echocardiographic findings in individuals without a previous history of ARF. The minimum diagnostic criteria in this setting are detailed above in Table 5.1 . Echocardiographic criteria for RHD are based on modalities that are available on basic portable machines: 2D, continuous-wave, and color-Doppler. The 2012 WHF guidelines clearly define what findings are consistent with definite and borderline RHD and also what are considered to be normal echocardiographic findings in children and adults. The guidelines define the morphological features of RHD and also clearly state how to differentiate trivial or physiologic regurgitation from pathologic regurgitation. This differentiation is critically important in RHD where it can influence the decision to prescribe painful and long-term secondary antibiotic prophylaxis.

To diagnose definite RHD on echocardiography in individuals without a history of ARF, both morphologic features of RHD and functional aortic and/or mitral valvular regurgitation and/or stenosis must be present in the absence of congenital heart disease. The only exception to the rule is that in those aged ≤20 years, borderline RHD of both the aortic and mitral valves is classified as definite RHD.

The borderline category only applies to those aged 20 years or younger, and it overlaps with normal findings in school-aged children. The rationale for introducing a borderline category in this age group was to increase the sensitivity in those who live in endemic regions with a high pretest probability of disease. The absolute clinical significance of borderline RHD is yet to be determined, though it is clear that those with borderline RHD are at an increased risk of both disease progression and morbidity.

In those settings where echocardiography is not widely available, the diagnosis of RHD still relies on clinical auscultatory findings of valvular regurgitation or stenosis. Auscultatory findings do not address the etiology of disease and as such the pretest probability of RHD will determine diagnostic and management strategies.

Clinical Assessment and Findings

Mild-to-moderate RHD is almost always asymptomatic in children and young adults. In regions of the world where echocardiography is not widely available, diagnosis and referral to tertiary centers will be based on clinical assessments and findings. Each of the classical lesions is associated with a number of clinical features that help guide the assessment and give guidance regarding severity of disease. Clinical assessment needs to be supplemented with ECG, chest X-ray, and blood tests. Whenever available, echocardiography should be used to validate clinical findings and determine etiology and severity of valvular dysfunction.

Innocent Cardiac Murmurs

Innocent murmurs may complicate the clinical evaluation of high-risk children and adults when cardiac auscultation is used to diagnose RHD. Figs. 5.3 and 5.4 demonstrate comparative phonographs and location of various innocent and pathologic murmurs. Cardiac auscultation is a fundamental process that requires active thought and listening, practice, and ongoing reinforcement of skills.

Fig. 5.3

Comparative phonograms for common valvular rheumatic heart disease lesions.

Copyright: Dr Ari Horton.

Fig. 5.4

Clinical auscultation for signs of rheumatic heart disease.

DM AR a , diastolic murmur of aortic regurgitation; DM MS, diastolic murmur of mitral stenosis; DM PR, diastolic murmur of pulmonary regurgitation; ESM AS a , ejection systolic murmur of aortic stenosis; LLSE, left lower sternal edge; LUSE, left upper sternal edge; MSE, midsternal edge; PSM MR a , pansystolic murmur of mitral regurgitation; PSM TR, pansystolic murmur of tricuspid regurgitation; RUSE, right upper sternal edge.

a Arrows indicate typical direction that the murmur radiates.

Copyright: Dr Ari Horton.

Innocent murmurs in the pediatric population

In the pediatric population, innocent murmurs occur in up to 25% of school age children on any given day and may confuse the clinical picture ( Table 5.2 ). Patients with innocent murmurs may have RHD, those without murmurs may have RHD, and those with murmurs and congenital heart disease may still have RHD. An Australian study found that doctor identification of any murmur had 38.2% sensitivity, 75.1% specificity, and 5.1% positive predictive value and the corresponding values for pathological murmurs were 20.6%, 92.2%, and 8.3% in relation to RHD.

Table 5.2

Key Differentiating Features on Examination Between Innocent and Pathological Murmurs.

Innocent Pathological
Usually occur in systole Can occur in systole, diastole, or both
Usually soft or vibratory Harsh
Grade 1/6 or 2/6 only Grade 1/6–6/6
Normal S1 and S2 Abnormal S2
Localized and do not radiate Often radiate
No associated clicks or gallops May be associated with added sounds (e.g., click)
Normal apex beat May be associated with displaced apex beat
No parasternal heave or thrill May be associated with a parasternal heave or thrill
Varies with respiration and position, often disappears on standing Specific variation with respiration and position according to impact of maneuver on lesion
Not associated with other signs of heart disease Associated with other signs of heart disease

Still’s murmur is the most common innocent murmur. It has a low-pitched musical or vibratory quality, best heard at the mid-to-lower sternal border and toward the apex and is not associated with any added sounds. Pulmonary flow murmurs are harsher and high-pitched, heard at the left upper sternal border, are often flow-dependent and vary with position, and disappear with Valsalva maneuver. Venous hum and carotid bruit are also common, but they are more easily distinguished from the pathologic murmurs of RHD. Venous hum is a continuous murmur that is heard below the clavicle and disappears when the patient is positioned supine, while the carotid bruit is localized to the carotid artery with or without any radiation. Innocent murmurs are associated with normal ECG and chest X-ray findings.

Pathological Murmurs in the Pediatric Population

The differentiation of innocent from pathological murmurs comes with critical thinking and assessment. The subtle differences lie in quality, pitch, location and radiation, added sounds and clicks, whilst dynamic maneuvers and positioning may assist ( Table 5.2 ). In childhood, common congenital heart defects such as ventricular septal defects, atrial septal defects, pulmonary stenosis, and aortic stenosis (AS) are associated with pathological murmurs and require differentiation from RHD. Regurgitant lesions because of congenital mitral valve and aortic valve disease are less common, and echocardiography is usually required to differentiate congenital from rheumatic etiology.

Pathological Murmurs in the Adult Population

In the adult population, degenerative and acquired processes become the leading cause of pathological valvular disease. On clinical history and examination alone, it is often difficult to determine the etiology of valvular disease: consideration should be given to the age of the patient and to background prevalence of RHD, particularly when clinical decisions are made without the aid of echocardiography. Clinical findings in the diagnosis of RHD in regions without access to echocardiography remain critically important. The examination findings in severe RHD have been summarised in Table 5.3 .

Table 5.3

Clinical Features Suggestive of severe Valvular Lesions on Clinical Examination.

Mitral Aortic
Regurgitation a Stenosis a Regurgitation a Stenosis a
Apex Thrusting ± thrill
Inferolaterally displaced
Inferolaterally displaced
Minimally displaced
Pulse Normal or jerky
Commonly atrial fibrillation
Normal or low volume
Often atrial fibrillation
Collapsing (or “water-hammer”)
See also box 5.1
Heart sounds Soft S1
Occasional S3
Loud S1
Short gap between S2 and the opening snap
Normal/soft S2
Occasional S3
Quiet or absent S2
Reversed split S2
Murmur Does not correlate with severity Long mid-diastolic murmur Short early-diastolic murmur
Austin Flint murmur
Does not correlate with severity
Other features Evidence of left heart failure
Carey Coombs murmur
Signs of pulmonary hypertension b
Pulmonary congestion and right heart failure
Signs of pulmonary hypertension b
Evidence of left heart failure
Wide pulse pressure
Evidence of left heart failure

a In mixed valve disease, the dominant lesion can be determined by assessing the impact of any lesion on the above parameters. In mixed mitral valve disease, the most discriminating factors are the apex beat and auscultatory findings; in mixed aortic valve disease, it is the apex beat, pulse character, and blood pressure. In multivalve disease involving mitral and aortic regurgitation, the key discriminating features are the pulse and blood pressure: sinus rhythm in the presence of a high systolic BP and wide pulse pressure suggests that aortic regurgitation is the dominant lesion. In those with significant mitral stenosis, clinical signs of aortic valve disease may be less evident. On the other hand, if there is evidence of a severe aortic valve lesion in the context of mitral stenosis, this suggests that the mitral stenosis is not severe.

b Right ventricular parasternal heave, loud pulmonary component of S2 (P2), palpable (P2), murmur of tricuspid regurgitation, right heart failure.

Mitral Regurgitation

Clinical symptoms

Mitral regurgitation (MR) is the most common manifestation of RHD. Symptoms develop as a result of increasing left atrial pressure, pulmonary venous hypertension and increased left ventricular (LV) end diastolic volumes and pressure. The acuity of the change in physiology often determines the severity of the symptoms and their recognition by patients and family members. Shortness of breath, especially during peak physical activity, may progress to shortness of breath at rest followed by clinical decompensation with HF and death. More rapid progression can occur in the setting of acute-on-chronic mitral valve disease or during significant intercurrent illnesses (see Chapter 16 ).

Clinical signs: mild-to-moderate mitral regurgitation

The hallmark of chronic MR is a harsh pansystolic murmur ( Fig. 5.5 ) heard best at the apex with radiation to the axilla. The direction of the regurgitant jet is usually posterolateral (hence the radiation to the axilla) due to the typical retraction of the posterior mitral valve leaflet and prolapse of the anterior leaflet. It is often high-pitched, and the intensity does not increase with inspiration, unlike the murmur of tricuspid regurgitation (TR). Less commonly, posterior mitral valve leaflet prolapse leads to an anteriorly-directed jet of MR with the pansystolic murmur heard medially at the lower left sternal edge. The LV apex will not be displaced in the setting of mild to moderate disease.

Fig. 5.5

Mitral regurgitation phonograms.

Copyright: Dr Ari Horton.

Clinical signs: moderate-to-severe mitral regurgitation

With progression of MR and ongoing ventricular dilatation, the apex beat becomes displaced laterally and inferiorly toward the axilla ( Table 5.3 ). An associated middiastolic murmur related to increased transmitral flow may develop. This is often called as a Carey-Coombs murmur. It is heard best with the bell of the stethoscope, while the patient is in the left lateral position and the breath held in end-expiration. In the setting of significant left atrial dilatation, atrial fibrillation may develop leading to an irregularly irregular heartbeat.


If there is acute valvulitis, the ECG may reveal first-degree heart block with a prolonged PR interval and or higher degrees of AV block (refer to age-specific normal ranges – see Chapter 3 ). In chronic RHD, the ECG is normal with mild-to-moderate mitral regurgitation. Moderate-to-severe disease often leads to classic ECG findings of left atrial enlargement with upright P waves in lead I, a bifid P wave in leads V1–V6 that gives the “M” pattern of P-mitrale. LV dilatation and hypertrophy leads to increased LV voltages ( Fig. 5.6 ). Right axis deviation (negative QRS in lead I), positive QRS complexes (dominant R-waves) in V1-2 (suggesting right ventricular hypertrophy), ST depression and T wave inversion in V1-3 (suggesting right ventricular strain), and peaked P waves (P pulmonale, suggesting right atrial hypertrophy) may appear in the setting of severe pulmonary hypertension.

Fig. 5.6

ECG with classical findings of chronic RHD with severe mitral regurgitation. The ECG shows sinus rhythm with right axis deviation, biatrial dilatation, right ventricular hypertrophy, and right ventricular strain in the setting of severe pulmonary hypertension from left heart disease (see main text for further details).

Chest X-ray

Chest X-ray (CXR) is normal in the setting of mild RHD, and it is helpful to exclude noncardiac pathologies that are common in resource-poor settings. As disease progresses, the CXR will demonstrate LV dilatation with cardiomegaly, left atrial enlargement with splaying of the carina, and pulmonary congestion with plethora if the MR is severe ( Fig. 5.7 ).

Fig. 5.7

Chest X-ray from a 14-year-old girl with severe mitral regurgitation, left ventricular dilatation, left ventricular dysfunction, pulmonary hypertension, and tricuspid regurgitation. Note the cardiomegaly, the dilated main pulmonary artery, and the splayed bronchi indicating left atrial enlargement. There is also evidence of pulmonary venous congestion and pulmonary vascular changes.

Mitral Stenosis

Clinical symptoms

Pure mitral stenosis (MS) is rare in the first decade of life; however, it becomes more common during childbearing years and has significant implications for pregnancy. The symptoms of pregnancy and MS overlap (see Chapter 9 ). Symptoms of MS develop as a result of progressive obstruction to LV inflow. The diastolic gradient between the left atrium and left ventricle is worsened with increased flow and heart rate, such as during illness, exercise or pregnancy, as well as in the presence of atrial fibrillation with a rapid ventricular rate. There is a clear correlation between the effective mitral valve orifice size and symptom onset and progression. Initial symptoms of progressive exertional dyspnoea usually develop with a mitral valve area <2 cm 2 , with the other symptoms of HF including orthopnoea and paroxysmal nocturnal dyspnoea manifesting as size decreases to <1.5 cm 2 . At advanced stages with massive left atrial enlargement, signs of cough, hemoptysis, chest pain, palpitations, and a hoarse voice (due to the left atrium mechanically compressing the left recurrent laryngeal nerve, known as Ortner’s syndrome) begin to develop. Less commonly, patients present with symptoms related to arterial embolism from the left atrium, such as an ischemic stroke or peripheral arterial occlusion.

Clinical signs: mild to moderate

The clinical signs of MS include an opening snap followed immediately by a low-pitched, diastolic rumble or decrescendo murmur heard best at the apex with the patient in a left lateral position ( Fig. 5.8 ). It is again accentuated by increasing heart rate with mild exercise. The duration of the murmur correlates with the severity of the MS. The opening snap is produced as the valve opens under the high left atrial pressures. The second phase of the murmur is in late diastole, as a result of atrial contraction, occurring immediately before the S1 sound creating a late diastolic, crescendo murmur. In the presence of atrial fibrillation, the active LV filling phase does not take place and the latter part of the MS murmur disappears.

Fig. 5.8

Mitral stenosis phonograms.

Copyright: Dr Ari Horton.

Clinical signs: moderate to severe

As MS worsens, left atrial pressure increases, forcing the mitral valve open earlier in diastole and the opening snap occurs earlier as does the initial decrescendo part of the murmur. Furthermore, as pulmonary hypertension increases, the pulse becomes small in volume and a right ventricular parasternal heave and loud or even palpable P2 become more prominent ( Table 5.3 ). Less commonly patients may have signs of systemic embolism from the left atrium, especially if they have previously had episodes of atrial fibrillation, which further increases stroke risk in MS.


It is important to confirm the baseline rhythm, namely sinus rhythm or atrial fibrillation. Atrial fibrillation is rare under 20 years old even in the setting of severe MS. Voltage criteria for left atrial enlargement, P-mitrale, and right ventricular hypertrophy are markers of severe disease.

Chest X-ray

Chest X-ray will demonstrate left atrial enlargement with a bulge sitting above the heart border in the left mediastinum with a splaying of the carina. Upper lobe diversion of blood flow and/or pulmonary congestion occurs in the setting of worsening HF. Calcification of the mitral valve apparatus may be seen on lateral CXR, especially in older patients. In the setting of established pulmonary hypertension, the main and hilar pulmonary arteries become prominent and there is also right ventricular hypertrophy on CXR.

Mixed Mitral Valve Disease

Clinical symptoms

With progression of RHD, severe mixed MS and MR often develops. The symptoms are insidious but are consistent with chronic progressive shortness of breath at rest, which is worse with any exertion. Exercise tolerance is often limited, and individuals will often self-limit activity. If pulmonary hypertension is present, then it may be associated with perioral cyanosis with activity.

Clinical signs: moderate to severe

There is both a short harsh pansystolic murmur at the apex and a short decrescendo diastolic murmur ( Fig. 5.9 ). Signs of pulmonary hypertension are usually present. Particular attention to the apex beat and auscultatory findings can help to determine which lesion is dominant ( Table 5.3 ).

Fig. 5.9

Mixed mitral valve disease phonograms.

Copyright: Dr Ari Horton.


Voltage criteria for left atrial enlargement and right ventricular hypertrophy are markers of severe disease together with right ventricular strain.

Chest X-ray

Chest X-ray will demonstrate left atrial enlargement with a bulge sitting above the heart border in the left mediastinum with a splaying of the carina, upper lobe diversion of blood flow, and/or pulmonary congestion in the setting of worsening HF. In the setting of established pulmonary hypertension, the main and hilar pulmonary arteries become prominent on CXR.

Aortic Regurgitation

Clinical symptoms

Moderate to severe aortic regurgitation (AR) often remains stable for years until the left ventricle begins to fail after chronic volume overload. Late symptoms of chronic AR include dyspnea on exertion, sometimes accompanied by frank congestive failure with orthopnea, paroxysmal nocturnal dyspnea, and edema (see Chapter 6 ). Severe AR carries a risk of decreased coronary perfusion pressure, which may manifest as angina despite normal coronary arteries. Initially, it may occur with exercise but eventually may develop at rest.

Clinical signs: mild-to-moderate aortic regurgitation

The clinical signs of mild-to-moderate AR include a soft, high-pitched blowing decrescendo early diastolic murmur best heard at the third intercostal space on the left sternal edge (Erb’s point), at end-expiration with the patient sitting upright and leaning forward ( Fig. 5.10 ). It is often also heard at the left lower sternal border and toward the apex, as the AR severity increases and jet lengthens, the flow is directed towards the apex of the heart. It decreases in intensity with inspiration. Generally, the length of the murmur correlates inversely with severity.

Fig. 5.10

Aortic regurgitation phonograms.

Copyright: Dr Ari Horton.

Clinical signs: moderate-to-severe aortic regurgitation

With progression to moderate-to-severe AR, the murmur at the left sternal edge shortens, and an added systolic ejection murmur develops at the right upper sternal edge reflecting increased stroke volume across the aortic valve. A characteristic Austin–Flint murmur may also be heard, which is a low-pitched middiastolic or presystolic murmur heard at the cardiac apex and radiating to the axilla, and this may be confused with the murmur of MS. This murmur is believed to be the result of the downward AR jet pressing on the anterior mitral valve leaflet, causing functional MS. The murmur is best heard in the left lateral decubitus position using the bell of the stethoscope at the apex.

In severe AR, abrupt distension and quick collapse of the pulses (known as the collapsing pulse or “water-hammer” pulse) may be visualized at the carotid artery (see box 5.1 ) or at the brachial, radial, ulnar, or femoral arteries. The collapsing pulse is defined as a pulse pressure that is greater than the diastolic pressure (i.e., the systolic pressure is double the diastolic pressure) and occurs as a result of the large stroke volume and aortic runoff from the aorta back to the left ventricle. The resulting wide pulse pressure is responsible for a variety of clinical signs associated with chronic severe AR ( box 5.1 ).

Box 5.1

Eponymous Signs in Chronic Severe Aortic Regurgitation

a Note that these signs are usually not present in acute aortic regurgitation (see Chapter 16 ).

  • Corrigan’s sign : visible carotid pulsation (common)

  • Traube’s sign : booming systolic and diastolic (“pistol shot”) sounds heard whilst auscultating the femoral arteries (relatively uncommon)

  • de Musset’s sign : bobbing of the head with each heartbeat (uncommon)

  • Quincke’s sign : visible capillary pulsation in the nailbed (uncommon)

  • Durozier’s sign : systolic murmur heard over femoral artery when it is compressed proximally and a diastolic murmur when it is compressed distally (uncommon)

  • Müller’s sign : systolic pulsations of the uvula (uncommon)

The collapsing pulse may also be elicited by palpation. Holding the patient’s arm at the wrist using the flat part of the fingers, the examiner lifts and straightens the arm vertically upwards. After a few seconds, the pulse should change in character from that of a prominent pulse to a tapping sensation. Lifting and straightening the arm accentuates the sign by emptying the arm more rapidly of blood due to gravity and straightens the natural kinks in the brachial artery and in the axillary/subclavian junction. These signs, however, are not specific for severe AR: anemia, thyrotoxicosis, arteriovenous malformations, and other high-flow states may also produce similar findings. Furthermore, it should be remembered that the pulse pressure narrows with the development of HF, attenuating the peripheral signs of AR.

In torrential AR (those at the most severe range of AR), the murmur is heard lying flat and the Korotkoff sounds may be heard almost down to the pressure of zero. Other clinical signs indicative of severe AR are summarised in Table 5.3 .


The electrocardiogram (ECG) often reveals a baseline tachycardia with or without increased LV voltages and nonspecific ST-T wave changes. Intermittent ischemia during exercise or periods of further vasodilatation may be seen infrequently.

Chest X-ray

In the setting of severe disease, the chest X-ray will demonstrate LV enlargement and may show a dilated ascending aorta.

Aortic Stenosis

Although isolated rheumatic AS is uncommon, it is important to understand the signs and symptoms of this uncommon manifestation of RHD. Clinical symptoms usually only result when there is a greater than 50% reduction in aortic valve area. Calcific AS in the elderly may occur in patients who had a history of ARF or RHD when younger. In this setting, the relative contribution of the calcific and the rheumatic processes may be uncertain. This concept and management of AS are discussed in more detail in Chapter 6 .

Clinical symptoms

Mild to moderate AS is most often asymptomatic. Symptoms are gradual in onset, slowly progressive and are often initially associated with exercise only. Survival is excellent during the asymptomatic phase although with the development of symptoms, mortality exceeds 90% within a few years, with symptoms of HF or syncope associated with the worst prognosis followed by angina.

Clinical signs: mild to moderate

The classical murmur of AS is an ejection systolic murmur at the right upper sternal edge which may radiate toward the neck ( Fig. 5.11 ). It is described as a high-pitched, crescendo-decrescendo ejection systolic murmur with the peak in early systole. Intensity of the murmur is not a good marker of the severity of disease.

Fig. 5.11

Aortic stenosis phonograms.

Copyright: Dr Ari Horton.

Clinical signs: moderate to severe

The murmur of AS will remain loudest at the right upper sternal border with radiation to the neck and to the apex. A loud, low-pitched, ejection systolic murmur is characteristically heard with a thrill over the aortic area and at the suprasternal notch. If the murmur radiates toward the apex (known as the Gallavardin phenomenon), it may be misinterpreted as mitral regurgitation, although the former tends to have a musical quality and does not radiate to the axilla. As the LV begins to fail, the ejection fraction declines resulting in a decreased intensity of the murmur with the peak intensity in later systole. The delay in closure of the aortic valve can also cause a paradoxically split S2. There are signs of a slowed and reduced carotid pulse upstroke ( Table 5.3 ).


ECG often demonstrates sinus rhythm with a baseline tachycardia and increased LV voltages meeting voltage criteria for LV hypertrophy. There may be secondary repolarization abnormalities, ST changes and T wave inversion in the lateral leads (leads I, aVL, and V5-6), consistent with LV strain.

Chest X-ray

Chest X-ray will often be normal in isolated AS unless there is associated mitral regurgitation. Calcification of the aortic valve may be visible on the lateral chest X-ray.

Tricuspid Regurgitation

Clinical symptoms

Tricuspid regurgitation is usually secondary to pulmonary hypertension due to MR or MS but may also be related (less commonly) to primary rheumatic disease of the tricuspid valve itself. Specific features of TR include abdominal discomfort and jaundice due to congestive hepatopathy, ascites due to increased porto-venous pressures, and weight loss due to indigestion and bowel wall edema, limiting appetite.

Clinical signs: mild to moderate

The early feature of TR is a low pitched pansystolic murmur at the left lower sternal edge ( Fig. 5.12 ). It increases with inspiration. If secondary to pulmonary hypertension, it has a higher pitch and is associated with a loud pulmonary component of the second heart sound (P2).

Fig. 5.12

Tricuspid regurgitation phonograms.

Copyright: Dr Ari Horton.

Clinical signs: moderate to severe

The pathognomonic clinical sign of severe TR is a raised jugular venous pressure and if the pulsation is palpable and monomorphic, it is known as Lancisi’s sign. Congestive hepatopathy is often associated with right-sided HF, jaundice, and tender hepatomegaly, which may be pulsatile. Occasionally, the systolic murmur of TR is transmitted to and heard over the liver. Peripheral edema, although nonspecific, is also often present. Anasarca (generalized swelling of the whole body) can occur in severe disease. Unilateral and bilateral pleural effusions are also seen frequently, particularly when the TR is secondary to left-sided valve disease.


ECG may demonstrate right atrial enlargement and right ventricular hypertrophy with increased voltages. It may be associated with voltage criteria consistent with biventricular hypertrophy and potentially a right ventricular strain pattern (ST/T-wave changes present in the inferior leads II, III, aVF and V1-V4) in the setting of severe pulmonary hypertension.

Chest X-ray

Chest X-ray will generally reveal right ventricular dilatation and right atrial enlargement with an atrial bulge at the right mediastinal border. If the TR is secondary to severe MR or MS then cardiomegaly and pulmonary congestion may be present.

Pulmonary Regurgitation

Clinical symptoms

Pulmonary regurgitation (PR), the rarest of the valves directly involved in RHD, is mostly secondary to the raised mean diastolic pulmonary pressures that result from left-sided valve disease. It is asymptomatic until severe right ventricular dilatation leads to decreased exercise capacity.

Clinical signs: mild to moderate

PR is often difficult to differentiate from AR. It produces a soft, high-pitched, early diastolic decrescendo murmur at the left sternal edge ( Fig. 5.13 ). Dynamic maneuvers can help to differentiate PR from AR. The cardiac murmur of PR increases in intensity during inspiration, the opposite occurs in the setting of AR.

Fig. 5.13

Pulmonary regurgitation phonograms.

Copyright: Dr Ari Horton.

Clinical signs: moderate to severe

The diastolic murmur of PR will shorten as it becomes more severe. In the setting of RHD, clinical signs are usually of concomitant aortic, mitral, and tricuspid valve disease.


ECG changes usually represent concomitant severe mitral valve disease.

Chest X-ray

Chest X-ray will demonstrate right ventricular dilatation and enlarged pulmonary arteries with a prominent pulmonary knuckle.

Multivalve Rheumatic Heart Disease

The most common manifestation of RHD is multivalve disease, and the most common cause of multivalve disease is RHD. Multivalve disease carries a high risk for ventricular dysfunction and symptomatic HF (see also Chapter 6 ).

Clinical symptoms

In the setting of multivalve disease, clinical symptoms usually relate to the predominant valvular lesion and to heart failure, pulmonary hypertension and arrhythmias.

Clinical signs: severe multivalve disease

When multivalve disease is severe, the chest wall might be wasted with visible ribs and reduced subcutaneous fat or muscular tissue. There will be a visible hyperdynamic impulse with the apex beat wide and displaced to the anterior axillary line. There will be a visible and palpable pulmonic component with heavy closure of the pulmonic valve due to pulmonary hypertension. The right ventricular heave may even lead to an asymmetric chest wall with the left side bulging in children. The heart sounds may be difficult to hear over the multiple murmurs, but there is often a loud P2 with the addition of a gallop rhythm (S3 and or S4). There will be loud, harsh systolic and diastolic murmurs heard throughout the chest that vary in intensity due to respiration and will radiate to the axilla and back ( Fig. 5.14 ). Pedal edema, ascites, hepatomegaly with or without pulsatility, raised jugular venous pressure, and dilated neck veins with bounding pulses are all markers of severe disease (see Table 5.3 ).

Fig. 5.14

Severe Multivalve RHD phonograms.


The ECG will often demonstrate sinus tachycardia with both right and left atrial enlargement and right and LV hypertrophy. Atrial fibrillation may be present.

Chest X-ray

Chest X-ray will demonstrate significant cardiomegaly and pulmonary plethora with or without bilateral pleural effusions and ascites. There may be a widened mediastinum with enlarged pulmonary arteries.

Echocardiography in Rheumatic Heart Disease

Echocardiography is a noninvasive portable diagnostic tool that plays an essential role both in the diagnosis and management of valvular heart disease and in determining the etiology and severity of HF ( Box 5.2 ). Left heart disease is also the most common cause of pulmonary hypertension in the modern era. Screening for pulmonary hypertension using echocardiography in patients with significant RHD is important because, untreated, morbidity and mortality levels are high and the diagnosis of pulmonary hypertension may be an indication for intervention ( Box 5.3 ). Given that echocardiography is much more sensitive and specific than clinical diagnosis and is more widely available than ever before (including point-of-care use and hand-held devices), it is now the primary means of diagnosing RHD in many regions of the world. Resource-poor countries are evolving strategies such as task-shifting to make this vital tool available and affordable for the most remote and poorest populations. Screening echocardiography with abbreviated protocols are being developed to facilitate task-shifting and rapid screening of large populations.

Box 5.2

Echocardiography is Vital in the Following Scenarios

  • Determining the etiology and severity of heart disease and/or HF

  • Diagnosis of RHD

  • Grading the severity and delineating the mechanism of valvular dysfunction

  • Serial assessments of LV size and function

  • Determining the echocardiographic probability of the presence or absence of pulmonary hypertension

  • Guiding the timing and nature of cardio-surgical intervention

  • Confirming the duration of secondary prophylaxis, in accordance with guidelines (see Chapter 11 )

  • Screening for latent (clinical and subclinical) RHD (see Chapter 13 )

  • Screening for pericardial effusion in the setting of ARF.

Box 5.3

Pulmonary Hypertension: Definition and Echocardiographic Features

a The recent definition of pHT has been lowered from a mean of ≥25 mmHg to ≥20 mmHg

b Chronic severe valve disease can also lead to systolic and/or diastolic dysfunction

c Absence of TR is insufficient to exclude pHT. Degree of TR does not correlate with peak TRmax. In the presence of severe TR, peak TRmax is significantly underestimated and should not be used alone to exclude pHT

d The RV-RA pressure gradient (RVSP) will only be an accurate reflection of the pulmonary artery systolic pressure (PASP) if there is no right ventricular outflow tract obstruction or pulmonary stenosis

e Where a higher systolic to diastolic ratio is associated with impaired global right ventricular function, haemodynamics, functional capacity, and clinical outcomes. In children, a ratio of >1.4 is associated with an especially poor prognosis, although no specific cut-off points have been established in adults with pHT

f Echocardiographic signs from at least two different categories (A/B/C) should be present to alter the echocardiographic probability of pHT when the peak TRmax is ≤3.4 m/s 3 . Category A (ventricles): RV/LV basal diameter ratio >1.0, flattening of the interventricular septum (LV eccentricity index >1.1 in systole and/or diastole); category B (pulmonary artery): RV outflow Doppler acceleration time <105 ms and/or middiastolic notching, early diastolic pulmonary regurgitation velocity >2.2 m/s; category C (IVC and RA): IVC diameter >2.1 cm with decreased respiratory collapse (<50% with sniff or <20% with quiet respiration), RA area (end-systole) >18 cm 2

g pHT is suggested echocardiographically when the PASP is >40 mmHg in adults. However, the PASP may correlate poorly with values obtained at right heart catheterization, which may partly be due to variability in estimating the RA pressure. Recent ESC guidelines on pulmonary hypertenion therefore propose that the TRmax together with other echocardiographic findings of pHT be used to report the echocardiographic probability of pHT and not PASP

h The RA pressure can be estimated using echocardiography based on the diameter and respiratory variation of the IVC. Normal pressure (0-5 mmHg): IVC diameter <2.1 cm + >50% collapse with sniff; intermediate (5-10 mmHg): when IVC diameter + collapse do not fit the definition of normal or high pressure; high pressure (10-20 mmHg): IVC diameter >2.1 cm + <50% collapse with sniff or <20% on quiet inspiration . Note that this is not validated in the paediatric population

i It is worth emphasizing that the definition of PH is based on demonstrating elevated mean pulmonary artery pressures (mPAP) at right heart catherization, while the most common echocardiographic method uses the peak TRmax to estimate the peak pulmonary artery systolic pressure (PASP).

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Feb 2, 2021 | Posted by in RHEUMATOLOGY | Comments Off on Clinical Evaluation and Diagnosis of Rheumatic Heart Disease
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