What is Rheumatic Heart Disease (RHD)?
Table of Contents
Understanding Rheumatic Heart Disease
Rheumatic Heart Disease (RHD) doesn’t always get the same attention as other cardiac conditions, but it absolutely should—especially in communities where it still causes significant, preventable harm.
As an Exercise Physiologist, I’ve worked with clients managing RHD across various stages of life. It’s one of the few forms of heart disease we can often prevent entirely—if we catch it early, treat infections quickly, and follow through with long-term care.
Let’s walk through what RHD is, how it develops, who it affects most, and how we can recognise and manage it effectively.
What is Rheumatic Heart Disease?
RHD Medical Definition
Rheumatic Heart Disease (RHD) is a chronic condition caused by damage to the heart valves following one or more episodes of acute rheumatic fever (ARF). ARF is an inflammatory disease that can develop after a Group A Streptococcus (GAS) throat infection—commonly known as strep throat—is left untreated or inadequately treated (WHO).
The immune response to ARF can cause scarring of the heart valves, impairing their ability to open and close properly. This disrupts normal blood flow, forcing the heart to work harder. Over time, this can lead to complications including heart failure, atrial fibrillation, stroke, and early death (Heart Foundation; AIHW).
The Link Between Rheumatic Fever and Rheumatic Heart Disease
RHD doesn’t appear overnight—it starts with rheumatic fever, the body’s inflammatory response to a strep throat infection. While ARF can affect the joints, skin, and brain, it’s the repeated damage to the heart valves that causes long-term consequences.
Not everyone who has rheumatic fever will develop RHD, but the risk increases with each episode—especially without follow-up care or ongoing antibiotic prevention. You can read more about the connection in this clinical overview from the Victorian Department of Health:
A Preventable Legacy: The History of RHD
Before antibiotics, rheumatic fever was a major cause of cardiovascular death worldwide. Today, we rarely see new cases in most high-income countries, thanks to timely access to healthcare and antibiotics. But the story is very different in some parts of Australia.
Among Aboriginal and Torres Strait Islander peoples, especially in remote and regional communities, RHD remains endemic. Indigenous Australians are up to 64 times more likely to have RHD than non-Indigenous Australians, and often at much younger ages (Australian Institute of Health and Welfare).
This isn't due to genetics. It’s largely driven by social determinants: poor housing, limited access to healthcare, and structural inequities that make early detection and treatment harder.
What Causes RHD?
The Role of Acute Rheumatic Fever
The chain begins with a strep throat infection. If not treated within 9–10 days, it can trigger an exaggerated immune response in some individuals, leading to inflammation across the body—particularly in the joints, skin, brain, and heart (WHO).
This is acute rheumatic fever (ARF). One episode of ARF can damage the heart valves, but repeated episodes—especially without secondary prevention—dramatically increase the risk of permanent scarring, which becomes rheumatic heart disease.
Risk Factors
Several conditions increase a person’s risk of developing RHD:
Overcrowded housing (facilitates spread of strep infections)
Limited access to antibiotics or health education
Low rates of throat swab testing or sore throat management
History of untreated strep throat or ARF
Indigenous Australian children aged 5–14 living in remote areas are especially vulnerable, with rates up to 150 times higher than the national average (AIHW).
Recognising Symptoms of RHD
One of the most difficult aspects of RHD is how silently it progresses. Many people don’t realise they’ve had ARF at all. Symptoms of valve damage might not appear for years.
Early Signs (often subtle)
Shortness of breath with exercise
Fatigue or poor exercise tolerance
Mild chest discomfort or palpitations
Advanced Symptoms (more obvious)
Noticeable heart murmurs (often picked up during a physical exam)
Swelling in the legs, ankles, or abdomen due to fluid retention
Severe shortness of breath, even at rest
Irregular heartbeat or fainting
If someone has a history of frequent sore throats, especially in a high-risk community, and experiences these symptoms—RHD should be on the radar.
How is RHD Diagnosed?
Diagnosis typically combines history, clinical exam, and several imaging or blood tests:
Echocardiogram (Echo): The gold standard. Uses ultrasound to visualise valve structure and function.
Electrocardiogram (ECG): Assesses rhythm abnormalities or chamber enlargement.
Chest X-ray: Helps identify heart enlargement or fluid in the lungs.
Blood Tests: Check for signs of inflammation and past exposure to strep bacteria.
Your GP or cardiologist will also review your medical history—including any known or suspected ARF episodes or frequent throat infections.
Treating RHD: What Are the Options?
There’s no “cure” for RHD once valve damage occurs, but with the right plan, progression can be slowed—and many people live full, active lives.
1. Long-Term Antibiotics (Secondary Prophylaxis)
To prevent further episodes of ARF, people diagnosed with RHD are typically prescribed long-acting penicillin injections every 3–4 weeks—often for 10 years or until age 21 (whichever is longer) (WHO Clinical Guidelines).
2. Medications for Heart Symptoms
Diuretics to manage fluid retention
Beta blockers or ACE inhibitors to support cardiac function
Anticoagulants in some cases to prevent clotting or stroke
3. Surgical Intervention
If valve damage becomes severe, valve repair or replacement may be needed. In Australia, Aboriginal and Torres Strait Islander patients often undergo heart valve surgery decades earlier than non-Indigenous patients, due to earlier disease onset and progression (Mealing et al., 2022)
Can You Exercise with RHD?
In most cases—yes. In fact, regular, appropriate physical activity is crucial for cardiovascular health, mood, and metabolic function. But not all exercise is safe for every person with RHD.
Your ability to exercise depends on:
The severity of valve damage
Whether you have symptoms like breathlessness or fluid overload
If you're taking heart medications that affect exercise tolerance
If you're living with RHD or supporting someone who is, I’ve put together a dedicated guide on how to exercise safely with rheumatic heart disease. It includes practical tips, red flags to watch for, and how to build a movement plan that fits your capacity.
Final Thoughts
Rheumatic Heart Disease is one of the clearest examples of a preventable chronic disease that still hits the hardest in communities with the least access to healthcare.
We can dramatically reduce the burden of RHD by:
Treating sore throats early in high-risk populations
Educating families and schools on the importance of follow-up
Supporting long-term antibiotic use when prescribed
Monitoring heart health and adapting lifestyle—including exercise—to the individual’s needs
If you're working with or caring for someone at risk, speak up early. RHD is manageable when we act before it gets serious—and that's something we can all help drive.
