Rheumatic Heart Disease

Issue

Vol. 2 No. 1 (2025)

Date Log

Submitted
September 8, 2024
Published
February 5, 2025

Rheumatic Heart Disease - Symptoms, Management and Prevention

https://doi.org/10.69512/ajphi.v1i2.69
Prabha Bhandari, MD
Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
Lumanti Manandhar
Rajiv Gandhi University of Health Sciences, Bangalore, India
Dipendra Kandel, MD
Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal

Corresponding Author(s) : Prabha Bhandari, MD

bhandariprabha991@gmail.com

The American Journal of Patient Health Info, Vol. 2 No. 1 (2025)

Abstract


  1. Rheumatic heart disease is a preventable heart disease that develops as a complication of acute rheumatic fever. Recurrent throat or skin infection by group A streptococcus triggers your immune system to attack your body tissues, causing a rheumatic fever.

  2. Rheumatic heart disease can cause permanent damage to your heart valves, leading to symptoms like shortness of breath, chest pain, and fatigue.

  3. Echocardiography is the key tool for diagnosing rheumatic heart disease and assessing the extent of valve damage and heart function.

  4. Treatment with penicillin may be required for an extended time in those who have significant heart damage.

  5. Poor living conditions, overcrowding, limited access to healthcare, and inadequate nutrition can increase the likelihood of exposure to streptococcal infections.

Keywords

Acute Rheumatic Fever Group A Streptococcus Heart failure Mitral stenosis Rheumatic Heart Disease (RHD)
Bhandari, MD, P., Manandhar, L., & Kandel, MD, D. (2025). Rheumatic Heart Disease - Symptoms, Management and Prevention. The American Journal of Patient Health Info, 2(1). https://doi.org/10.69512/ajphi.v1i2.69
Download Citation
Endnote/Zotero/Mendeley (RIS)
BibTeX
References
  1. Dooley LM, Ahmad TB, Pandey M, Good MF, Kotiw M. Rheumatic heart disease: A review of the current status of global research activity. Autoimmunity Reviews [Internet]. 2021 Feb 1;20(2):102740. Available from: https://doi.org/10.1016/j.autrev.2020.102740
  2. Pandian NG, Kim JK, Arias-Godinez JA, Marx GR, Michelena HI, Mohan JC, et al.
  3. Recommendations for the Use of Echocardiography in the Evaluation of Rheumatic Heart Disease: A Report from the American Society of Echocardiography. Journal of the American Society of Echocardiography [Internet]. 2023 Jan 1;36(1):3–28. Available from: https://doi.org/10.1016/j.echo.2022.10.009
  4. Rheumatic heart disease - Level 3 cause [Internet]. Institute for Health Metrics and Evaluation. Available from: https://www.healthdata.org/research-analysis/diseases-injuries-risks/factsheets/2021-rheumatic-heart-disease-level-3-disease
  5. Noubiap JJ, Agbor VN, Bigna JJ, Kaze AD, Nyaga UF, Mayosi BM. Prevalence and progression of rheumatic heart disease: a global systematic review and meta-analysis of population-based echocardiographic studies. Scientific Reports [Internet]. 2019 Nov 19;9(1). Available from: https://doi.org/10.1038/s41598-019-53540-4
  6. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, et al. 2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation [Internet]. 2021 Feb 2;143(5). Available from: https://doi.org/10.1161/cir.0000000000000923
  7. Lumngwena EN, Skatulla S, Blackburn JM, Ntusi N a. B. Mechanistic implications of altered protein expression in rheumatic heart disease. Heart Failure Reviews [Internet]. 2020 Jul 11;27(1):357–68. Available from: https://doi.org/10.1007/s10741-020-09993-1
  8. Franczyk B, Gluba-Brzózka A, Rysz-Górzyńska M, Rysz J. The role of inflammation and oxidative stress in rheumatic heart disease. International Journal of Molecular Sciences [Internet]. 2022 Dec 13;23(24):15812. Available from: https://doi.org/10.3390/ijms232415812
  9. Gewitz MH, Baltimore RS, Tani LY, Sable CA, Shulman ST, Carapetis J, et al. Revision of the Jones criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography. Circulation [Internet]. 2015 May 19;131(20):1806–18. Available from: https://doi.org/10.1161/cir.0000000000000205
  10. Jack S, Moreland NJ, Meagher J, Fittock M, Galloway Y, Ralph AP. Streptococcal serology in acute rheumatic fever patients. The Pediatric Infectious Disease Journal [Internet]. 2019 Jan 1;38(1):e1–6. Available from: https://doi.org/10.1097/inf.0000000000002190
  11. Kumar RK, Antunes MJ, Beaton A, Mirabel M, Nkomo VT, Okello E, et al. Contemporary Diagnosis and Management of rheumatic heart Disease: Implications for Closing the gap: A scientific statement from the American Heart Association. Circulation [Internet]. 2020 Nov 17;142(20). Available from: https://doi.org/10.1161/cir.0000000000000921
  12. Dass C, Kanmanthareddy A. Rheumatic heart disease [Internet]. StatPearls - NCBI Bookshelf. 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538286/
  13. Aremu OO, Samuels P, Jermy S, Lumngwena EN, Mutithu D, Cupido BJ, et al. Cardiovascular imaging modalities in the diagnosis and management of rheumatic heart disease. International Journal of Cardiology [Internet]. 2021 Feb 1;325:176–85. Available from: https://doi.org/10.1016/j.ijcard.2020.09.049
  14. Berhanu H, Mossie A, Morankar S, Gemechu T, Tegene E. Echocardiographic Parameters and Complication Profiles Among Adult Patients with Rheumatic Heart Disease at Jimma Medical Center. Vascular Health and Risk Management [Internet]. 2024 Apr 1;Volume 20:157–66. Available from: https://doi.org/10.2147/vhrm.s451957
  15. Zakkar M, Amirak E, Chan KMJ, Punjabi PP. Rheumatic Mitral Valve Disease: current surgical status. Progress in Cardiovascular Diseases [Internet]. 2009 May 1;51(6):478–81. Available from: https://doi.org/10.1016/j.pcad.2008.08.008
  16. Parks T, Narube L, Perman ML, Sakumeni K, Fong JJ, Engelman D, et al. Population-based assessment of cardiovascular complications of rheumatic heart disease in Fiji: a record-linkage analysis. BMJ Open [Internet]. 2023 Apr 1;13(4):e070629. Available from: https://doi.org/10.1136/bmjopen-2022-070629
  17. Vasconcelos M, Vasconcelos L, Ribeiro V, Campos C, Di-Flora F, Abreu L, et al. Incidence and predictors of stroke in patients with rheumatic heart disease. Heart [Internet]. 2021 Jan 7;107(9):748–54. Available from: https://doi.org/10.1136/heartjnl-2020-318054
  18. Hwang JJ, Kuan P, Lin SC, Chen WJ, Lei MH, Ko YL, et al. Reappraisal by transesophageal echocardiography of the significance of left atrial thrombi in the prediction of systemic arterial embolization in rheumatic mitral valve disease. The American Journal of Cardiology [Internet]. 1992 Sep 1;70(7):769–73. Available from: https://doi.org/10.1016/0002-9149(92)90557-f
  19. Ralph AP, Noonan S, Wade V, Currie BJ. The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease. The Medical Journal of Australia [Internet]. 2020 Nov 15;214(5):220–7. Available from: https://doi.org/10.5694/mja2.50851
  20. Shimanda PP, Shumba TW, Brunström M, Iipinge SN, Söderberg S, Lindholm L, et al. Preventive interventions to reduce the burden of rheumatic heart disease in populations at risk: a systematic review. Journal of the American Heart Association [Internet]. 2024 Mar 5;13(5). Available from: https://doi.org/10.1161/jaha.123.032442
  21. Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST, et al. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis. Circulation [Internet]. 2009 Mar 24;119(11):1541–51. Available from: https://doi.org/10.1161/circulationaha.109.191959
Read More
Author biographies is not available.
Download
PDF XML
Statistic
Read Counter : 1969 Download : 467

Prabha Bhandaria, Lumanti Manandharb, Dipendra Kandelc

a Kathmandu University School of Medical Sciences, Dhulikhel, Nepal

b Rajiv Gandhi University of Health Sciences, Bangalore, India

c Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal

Background

Rheumatic heart disease (RHD) is a chronic condition that develops as a complication of rheumatic fever. Rheumatic fever is an inflammatory disease that can occur after two to four weeks of your untreated or inadequately treated streptococcal throat infection or skin infection, caused explicitly by group A Streptococcal infection. 1

Rheumatic fever triggers an immune response in your body, where your immune system attacks various tissues, including the heart, joints, skin, and nervous system. If your heart is affected, it can lead to the development of rheumatic heart disease. 1 The most significant impact of rheumatic heart disease is the damage it causes to your heart valves, particularly your mitral valve. The inflammation causes the heart valves to become thickened and less flexible, leading to valvular dysfunction, including regurgitation and narrowing of your heart valves. 2 In 2021, the global burden of RHD is substantial, with an estimated prevalence of 43·3 million to 67·6 million, resulting in 373 000 deaths. 3 The prevalence of RHD varies significantly by region, with the highest rates observed in sub-Saharan Africa, South Asia, and among Indigenous populations in developed countries. 1,4

Risk Factors for Rheumatic Heart Disease

Figure 1.

  • Untreated and Repeated Streptococcal Infections: Recurrent and untreated strep infections can increase your risk of developing RHD by triggering an abnormal immune response that damages the heart valves. 5
  • Age and Gender: RHD is more common in children and young adults, particularly between the ages of 5 and 15. If you are female, you are at a slightly higher risk than males. 5
  • Socioeconomic Factors: Your socioeconomic factors, such as poor living conditions, overcrowding, limited access to healthcare, and inadequate nutrition, can increase the likelihood of spreading streptococcal infections. It hinders the prompt and effective treatment of these infections, contributing to your increased risk of RHD. 6,7
  • Environmental Factors: Environmental factors, such as living in densely populated areas with poor sanitation, might contribute to the spread of streptococcal infections, increasing your risk of RHD. 6

Symptoms of Rheumatic Heart Disease

RHD symptoms may not show up for several years. The appearance of your symptoms depends on the kind and extent of the damage to your heart valves and which heart valves are involved. Your common symptoms include:

Figure 2.

  • Shortness of Breath: As your heart valve damage progresses and your heart's pumping efficiency decreases, you may experience difficulty breathing. It occurs mainly during physical activities or when you are lying flat. 3,5
  • Fatigue: Reduced heart function can decrease blood flow to your body's organs and tissues. As a result, you will experience persistent fatigue and weakness. 3,5
  • Palpitations: You can feel irregular heartbeats or palpitations. It occurs due to heart valve abnormalities and changes in your heart's electrical conduction system. This electrical disturbance is caused because of the enlargement of the left upper chamber of your heart. 3,5
  • Chest Pain: Some of you may experience chest discomfort or pain, particularly when your heart's blood supply is inadequate or when your heart is strained due to valve issues. 3,5
  • Swelling: Swelling of your feet, ankles, or legs can develop. The inability of your heart to pump blood may cause fluid buildup in your lower extremities. 3,5
  • Cough: You may develop a persistent cough often accompanied by frothy or pink-tinged sputum. This can indicate fluid accumulation in your lungs (pulmonary congestion). 3,5

Diagnosis of Rheumatic Heart Disease

Figure 3.

  • Streptococcal Infection Testing: If you have RHD, you may have had a recent or current streptococcal infection. Thus, streptococcal testing is of utmost importance. A swab of your throat can be cultured to identify the presence of streptococcus bacteria. 8,9
  • Blood Test: Your doctor might perform your blood tests to measure specific markers of inflammation (such as C-reactive protein or erythrocyte sedimentation rate). They will also test for the presence of streptococcal antibodies. Elevated levels of these markers can indicate ongoing inflammation and might suggest a recent streptococcal infection. 8,9
  • Chest X-ray: A chest X-ray can provide information about the size and shape of your heart. If you have advanced RHD, your heart might be enlarged, and there could be signs of fluid accumulation in the lungs. 10
  • Electrocardiogram (ECG): An ECG records the electrical activity of your heart. It can help identify any irregularities in your heart's rhythm or conduction system that might be related to RHD. 10
  • Echocardiogram: An echocardiogram is a key diagnostic tool for RHD. It uses sound waves to create detailed images of your heart's structure and function. It can help identify damage to your heart valves, such as thickening, narrowing, or leakage, which are common features of RHD. Mitral regurgitation is commonly seen in RHD. 11
  • Cardiac MRI: In some cases, your doctor may recommend obtaining a cardiac MRI for more detailed images of your heart's structure and function. This can provide additional information about the extent of valve damage. 12

Treatment and Management of Rheumatic Heart Disease

Figure 4.

  • Medications: Medications might be prescribed to manage heart failure symptoms. Medications such as diuretics can help reduce fluid retention, and angiotensin-converting enzyme inhibitors like captopril and enalapril can lower your blood pressure and improve your heart function. Beta-blockers might be prescribed to slow down your heart rate and reduce strain on your heart. 10
  • Minimally Invasive Procedure: If you are symptomatic and only have a narrow mitral valve without other issues, your doctor might advise you to undergo valvuloplasty. Valvuloplasty is a procedure that makes your heart valves as normal as possible by enlarging them depending on the severity. 10
  • Surgery: In cases where your heart valves are significantly damaged and not functioning properly, surgical intervention might be necessary. Valve repair or replacement surgeries are standard procedures to address this issue and improve your heart function. Valve repair needs more expertise and carries the risk of reoperation. So, valve replacement is the most practically preferred surgical option. In valve replacement surgery, your entire valve is removed, and an artificial valve is kept in place of them. The replaced artificial valves can be made from either carbon-coated plastic or tissue derived from animal valves or donated human valves. 5

Complications of Rheumatic Heart Disease

Figure 5.

1. Valvular Heart Disease: RHD primarily affects your heart valves, leading to valvular damage. The valves of your heart can become thickened, scarred, or distorted, impairing their ability to open and close properly. This can result in conditions such as:

  • Mitral stenosis: The mitral valve narrows, making it difficult for blood to flow from your heart's left atrium to the left ventricle.
  • Mitral regurgitation: The mitral valve doesn't close properly, causing blood to leak back into your left atrium.
  • Aortic stenosis: The aortic valve becomes narrowed, obstructing the blood flow from your left ventricle to the aorta.
  • Aortic regurgitation: The aortic valve doesn't close properly, causing blood to flow back from the aorta into your left ventricle. 5,13,14

2. Heart Failure: As the valve damage worsens, your heart's ability to pump blood efficiently can be compromised, leading to heart failure. 15

3. Infective Endocarditis: The damaged heart valves can create an environment where bacteria are more likely to infect your heart lining or valves, leading to infective endocarditis. This is a severe and potentially life-threatening infection. 15

4. Arrhythmias: RHD causes changes in your heart's structure and function, resulting in irregular heart rhythms or arrhythmias. These can range from mild palpitations to more severe rhythm disturbances like atrial fibrillation. 13

5. Pulmonary Hypertension: Over time, the increased strain on your heart due to valve damage can lead to high blood pressure in the pulmonary arteries, which can affect your lungs and heart function. 13

6. Stroke: Some of you might develop blood clots in the left upper chamber of your heart due to atrial fibrillation. If a clot dislodges and travels to your brain, it can cause a stroke.Blood clots can also travel to other parts of your body, causing blockages in your blood vessels (embolism) and potentially affecting your organs. 16,17

Prevention of Rheumatic Heart Disease

Preventing RHD primarily involves prompt treatment of streptococcal infections. Here are key strategies for preventing RHD:

Figure 6.

1. Primordial Prevention

  • Improving access to healthcare: Your access to healthcare must be ensured, especially in regions with high incidence rates of streptococcal infections and rheumatic fever. This includes access to healthcare facilities for diagnosis, treatment, and follow-up care.
  • Health education and awareness: You must know the importance of seeking medical care for streptococcal infections and completing antibiotic courses. If your symptoms of rheumatic fever are recognized early, it can aid in early intervention of rheumatic fever and prevention of RHD.
  • Promoting hygiene and sanitation: you must implement measures to improve hygiene, sanitation, and your living conditions. This helps in reducing the spread of streptococcal infections in your communities. 18

2. Primary Prevention

  • Prompt treatment of strep infections: It is crucial to promptly and effectively treat your streptococcal infections, throat or skin, with appropriate antibiotics. Treating these infections early reduces your risk of developing rheumatic fever. You must ensure that antibiotic treatments are completed as a healthcare professional prescribes to eradicate the bacteria fully.
  • Early detection and treatment of rheumatic fever: Recognizing and promptly treating your rheumatic fever is essential. 5,19

3. Secondary Prevention

  • Regular antibiotic prophylaxis: If you have rheumatic fever, you are often prescribed prophylactic antibiotics to prevent recurrence and minimize the risk of developing RHD. Your doctor will prescribe you intramuscular benzathine penicillin G every four weeks. If you cannot tolerate injections, oral penicillin V is an alternative. You should continue the antibiotic for at least ten years or until you reach 40, whichever is longer. Lifelong prophylaxis may be necessary if you are at high risk of group A streptococcus exposure. 5,20

Questions for your Doctor

  1. Is the damage caused by RHD to my heart curable?
  2. Is it safe for me to get pregnant with RHD?
  3. What should I do if I experience a flare-up or new RHD-related symptoms?
  4. Are there any specific dietary recommendations or restrictions for individuals with RHD?
  5. How does RHD impact physical activity and exercise, and are there any limitations or precautions I should follow?

Conflict of Interest Statement

PB is a non-paid research assistant at ehealthyinfo. LM worked as a paid freelance medical journalist for ehealthyinfo from 2022-23. DK is a non-paid research assistant at ehealthyinfo. No other conflicts of interest were declared.

Peer Reviewed By

Abhushan Poudyal, MD

Oregon Health & Scienc, University, Portland, OA, USA

References

  1. Dooley LM, Ahmad TB, Pandey M, Good MF, Kotiw M. Rheumatic heart disease: A review of the current status of global research activity. Autoimmunity Reviews [Internet]. 2021 Feb 1;20(2):102740. Available from: https://doi.org/10.1016/j.autrev.2020.102740
  2. Pandian NG, Kim JK, Arias-Godinez JA, Marx GR, Michelena HI, Mohan JC, et al. Available from: https://pubmed.ncbi.nlm.nih.gov/36428195/
  3. Rheumatic heart disease - Level 3 cause [Internet]. Institute for Health Metrics and Evaluation. Available from: https://www.healthdata.org/research-analysis/diseases-injuries-risks/factsheets/2021-rheumatic-heart-disease-level-3-disease
  4. Noubiap JJ, Agbor VN, Bigna JJ, Kaze AD, Nyaga UF, Mayosi BM. Prevalence and progression of rheumatic heart disease: a global systematic review and meta-analysis of population-based echocardiographic studies. Scientific Reports [Internet]. 2019 Nov 19;9(1). Available from: https://doi.org/10.1038/s41598-019-53540-4
  5. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, et al. 2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation [Internet]. 2021 Feb 2;143(5). Available from: https://doi.org/10.1161/cir.0000000000000923
  6. Lumngwena EN, Skatulla S, Blackburn JM, Ntusi N a. B. Mechanistic implications of altered protein expression in rheumatic heart disease. Heart Failure Reviews [Internet]. 2020 Jul 11;27(1):357–68. Available from: https://doi.org/10.1007/s10741-020-09993-1
  7. Franczyk B, Gluba-Brzózka A, Rysz-Górzyńska M, Rysz J. The role of inflammation and oxidative stress in rheumatic heart disease. International Journal of Molecular Sciences [Internet]. 2022 Dec 13;23(24):15812. Available from: https://doi.org/10.3390/ijms232415812
  8. Gewitz MH, Baltimore RS, Tani LY, Sable CA, Shulman ST, Carapetis J, et al. Revision of the Jones criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography. Circulation [Internet]. 2015 May 19;131(20):1806–18. Available from: https://doi.org/10.1161/cir.0000000000000205
  9. Jack S, Moreland NJ, Meagher J, Fittock M, Galloway Y, Ralph AP. Streptococcal serology in acute rheumatic fever patients. The Pediatric Infectious Disease Journal [Internet]. 2019 Jan 1;38(1):e1–6. Available from: https://doi.org/10.1097/inf.0000000000002190
  10. Kumar RK, Antunes MJ, Beaton A, Mirabel M, Nkomo VT, Okello E, et al. Contemporary Diagnosis and Management of rheumatic heart Disease: Implications for Closing the gap: A scientific statement from the American Heart Association. Circulation [Internet]. 2020 Nov 17;142(20). Available from: https://doi.org/10.1161/cir.0000000000000921
  11. Dass C, Kanmanthareddy A. Rheumatic heart disease [Internet]. StatPearls - NCBI Bookshelf. 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538286/
  12. Aremu OO, Samuels P, Jermy S, Lumngwena EN, Mutithu D, Cupido BJ, et al. Cardiovascular imaging modalities in the diagnosis and management of rheumatic heart disease. International Journal of Cardiology [Internet]. 2021 Feb 1;325:176–85. Available from: https://doi.org/10.1016/j.ijcard.2020.09.049
  13. Berhanu H, Mossie A, Morankar S, Gemechu T, Tegene E. Echocardiographic Parameters and Complication Profiles Among Adult Patients with Rheumatic Heart Disease at Jimma Medical Center. Vascular Health and Risk Management [Internet]. 2024 Apr 1;Volume 20:157–66. Available from: https://doi.org/10.2147/vhrm.s451957
  14. Zakkar M, Amirak E, Chan KMJ, Punjabi PP. Rheumatic Mitral Valve Disease: current surgical status. Progress in Cardiovascular Diseases [Internet]. 2009 May 1;51(6):478–81. Available from: https://doi.org/10.1016/j.pcad.2008.08.008
  15. Parks T, Narube L, Perman ML, Sakumeni K, Fong JJ, Engelman D, et al. Population-based assessment of cardiovascular complications of rheumatic heart disease in Fiji: a record-linkage analysis. BMJ Open [Internet]. 2023 Apr 1;13(4):e070629. Available from:https://doi.org/10.1136/bmjopen-2022-070629
  16. Vasconcelos M, Vasconcelos L, Ribeiro V, Campos C, Di-Flora F, Abreu L, et al. Incidence and predictors of stroke in patients with rheumatic heart disease. Heart [Internet]. 2021 Jan 7;107(9):748–54. Available from: https://doi.org/10.1136/heartjnl-2020-318054
  17. Hwang JJ, Kuan P, Lin SC, Chen WJ, Lei MH, Ko YL, et al. Reappraisal by transesophageal echocardiography of the significance of left atrial thrombi in the prediction of systemic arterial embolization in rheumatic mitral valve disease. The American Journal of Cardiology [Internet]. 1992 Sep 1;70(7):769–73. Available from: https://doi.org/10.1016/0002-9149(92)90557-f
  18. Ralph AP, Noonan S, Wade V, Currie BJ. The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease. The Medical Journal of Australia [Internet]. 2020 Nov 15;214(5):220–7. Available from: https://doi.org/10.5694/mja2.50851
  19. Shimanda PP, Shumba TW, Brunström M, Iipinge SN, Söderberg S, Lindholm L, et al. Preventive interventions to reduce the burden of rheumatic heart disease in populations at risk: a systematic review. Journal of the American Heart Association [Internet]. 2024 Mar 5;13(5). Available from: https://doi.org/10.1161/jaha.123.032442
  20. Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST, et al. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis. Circulation [Internet]. 2009 Mar 24;119(11):1541–51. Available from: https://doi.org/10.1161/circulationaha.109.191959

Most read articles by the same author(s)

1 2 > >> 

Similar Articles

1 2 3 4 5 > >> 

You may also start an advanced similarity search for this article.