Pedi Acquired Cardiovascular Study Guide
Rheumatic Fever
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*delayed sequela of group A streptococcal pharyngeal infection.
occurs more often in school-age children between 5 and 15 years of age in areas where
streptococcal pharyngitis is more prevalent, especially during the colder months.
It usually develops 2 to 4 weeks after the initial streptococcal infection.
child develops an antibody response to surface proteins of the bacteria.
The antibodies then cross-react with antigens in cardiac muscle and neuronal and
synovial tissues, causing carditis, arthritis, and chorea (involuntary random, jerking
movements).
ARF affects the joints, central nervous system, skin, and subcutaneous tissue and causes
chronic, progressive damage to the heart and valves.
Rheumatic Heart Disease (RHD) is the most common complication of RF, that damages
the heart valves.
Assessment
*Jones Criteria:
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Diagnosis of acute rheumatic fever requires the presence of either two major criteria or
one major plus two minor criteria.
Major Criteria
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Carditis
Migratory polyarthritis
Subcutaneous nodules (occur in crops over bony prominences)
Erythema marginatum (rash on trunk and proximal extremities)
Sydenham chorea – St. Vitus Dance (5th manifestation)
o CNS involvement
o Sudden, aimless movements of the extremities
o Involuntary facial grimaces
o Speech disturbances
o Emotional lability
o Muscle weakness
Minor Criteria
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Polyarthralgia
Elevated erythrocyte sedimentation rate or C-reactive protein
Prolonged PR interval (unless carditis is a major criterion)
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recent medical history for risk factors, such as documented streptococcal infection or sore
throat within the past 2 to 3 weeks, or for history of ARF.
Auscultate the heart, noting a murmur.
Throat culture will provide definitive diagnosis of current streptococcal infection, while
streptococcal antibody tests may yield evidence of recent infection.
Echocardiogram is required to determine if carditis is present.
Management
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managing inflammation and fever, eradicating the bacteria, preventing permanent heart
damage, and preventing recurrences.
*A full 10-day course of penicillin therapy (or equivalent) is used along with
corticosteroids and nonsteroidal anti-inflammatory drugs.
Children without valvular disease will receive continued prophylaxis with monthly
intramuscular injections of penicillin G benzathine or daily oral doses of penicillin or
erythromycin (if allergic to penicillin’s) following the initial illness to prevent a new
streptococcal infection and recurrent ARF.
Prophylaxis is continued until adulthood
Some children may require a neuroleptic agent such as haloperidol (Haldol) for
management of chorea.
Administer corticosteroids or nonsteroidal anti-inflammatory agents for control of joint
pain and swelling.
Kawasaki Disease
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*acute systemic vasculitis occurring mostly in children 6 months to *5 years of age.
It is the leading cause of acquired heart disease among children and occurs more often in
the winter and summer
It is a self-limited syndrome but can cause cardiovascular complications such as coronary
artery aneurysm and cardiomyopathy
Pathophysiology
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etiology is still unknown
appears to be an autoimmune response mediated by cytokine-induced endothelial cell
surface antigens that leads to vasculitis in the medium size arteries, including the
coronary arteries
Generalized systemic vasculitis occurs in the blood vessels throughout the body due to
the inflammation and edema and can lead to coronary dilation or aneurysm
*Assessment
Three Phases:
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Acute - sudden high fever, unresponsive to antipyretics and antibiotics
Subacute - end of fever through end of all KD clinical signs
Convalescent - clinical signs resolved, but laboratory values not returned to normal;
completed with normal values (6-8 weeks)
Lab and Diagnostic Testing
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CBC count may reveal mild to moderate anemia, an elevated white blood cell count
during the acute phase, and significant thrombocytosis in the later phase
The erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP) level are
elevated.
Echocardiogram is performed as soon as possible after the diagnosis is confirmed to
provide a baseline of a healthy heart or to evaluate for coronary artery involvement
Management
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reducing inflammation in the walls of the coronary arteries and preventing coronary
thrombosis.
Chronic management of children developing aneurysms during the initial phase is
directed toward preventing myocardial ischemia.
*In the acute phase, high-dose aspirin (80-100 mg/kg/day) in four divided doses daily for
fever
*single infusion of intravenous immunoglobulin (IVIG)
Administer intravenous and oral fluids as ordered, evaluating intake and output carefully.
*Assess frequently for signs of developing heart failure such as tachycardia, gallop,
decreased urine output, or respiratory distress
Provide acetaminophen for fever management and apply cool cloths as tolerated. Keep
the environment quiet and cluster nursing care activities to decrease stimulation
Apply petrolatum jelly or another lubricating ointment to the lips.
Encourage the older child to suck on ice chips; the younger child may suck on a cool,
moist washcloth.
Popsicles are also soothing.
Provide comfortable positioning, particularly if the child has joint pain or arthritis.
Teach parents to continue to monitor the child’s temperature after discharge until the
child has been afebrile for several days.
Children with prolonged or recurrent fever may require a second dose of IVIG.
Inform parents that irritability may last for up to 2 months after initial diagnosis
It is important to avoid nonsteroidal anti-inflammatory agents while aspirin therapy is
ongoing
*Avoid measles and varicella vaccination for 11 months after high-dose IVIG
administration