Rheumatic heart disease: how a sore throat can scar a heart valve

The World Health Organization describes rheumatic heart disease as the result of inflammation and scarring of the heart valves caused by rheumatic fever. Valves are the flaps that keep blood moving in one direction through the heart; if you want a refresher on how they fit into the whole organ, see how the heart works.

Rheumatic fever itself is an autoimmune reaction to a throat infection with group A streptococcus, a common bacterium. Autoimmune means the body's own defences mistakenly attack healthy tissue. Healthdirect, the Australian public health information service, notes that rheumatic heart disease can involve one or more of the four heart valves and is preventable.

The chain begins with a group A strep infection, usually of the throat. In a small number of people the immune response to that infection turns against the body, producing rheumatic fever one to five weeks later, according to the US Centers for Disease Control and Prevention. The NHS calls rheumatic fever a very rare complication, and says most people who have a bacterial throat infection do not develop it.

Rheumatic fever can inflame the heart, joints, brain and skin. When it inflames the heart, the valves can be damaged. The NHS adds that people who have had rheumatic fever once are more likely to get it again, and the heart damage can take years to appear. That is one reason preventing recurrences is a central part of care. Our page on sore throats and rheumatic fever covers the earlier step in more detail.

The WHO fact sheet (dated 24 January 2025) states that rheumatic heart disease affects an estimated 55 million people worldwide and claims approximately 360 000 lives each year, mostly in low- or middle-income countries. It describes the condition as the most commonly acquired heart disease in people under 25.

Rheumatic fever mainly affects children and adolescents, and the WHO names overcrowded or poor living conditions as the greatest risk, along with marginalized communities, including Indigenous populations. The same fact sheet says rheumatic heart disease remains prevalent in sub-Saharan Africa. Women sometimes learn they have the condition only when they become pregnant, a topic covered in pregnancy and the heart.

Early on there may be nothing to notice. Healthdirect says people with mild disease may have no symptoms, and a doctor may hear a heart murmur (an extra whooshing sound) through a stethoscope. It also warns that symptoms may not reflect how severe the disease is.

When valve damage progresses, the WHO lists these signs:

• chest pain
• shortness of breath
• swelling of the abdomen, hands or feet
• fatigue
• a rapid or irregular heartbeat

These symptoms are common to many heart conditions, so they point toward a check-up rather than to any one diagnosis.

Healthdirect explains that a doctor reviews symptoms and history, examines the person, and then arranges an echocardiogram, an ultrasound of the heart, to assess the valves and blood flow. Listening for a murmur is often the first clue, and the scan confirms what is happening inside. The WHO notes that many cases are diagnosed late, when heart damage is already severe, and that health workers may lack the knowledge to diagnose and manage strep throat appropriately.

For a wider look at what valve damage means for the heart, see heart valve problems.

The WHO describes two levels of prevention. Treating strep throat with appropriate antibiotics prevents rheumatic fever in the first place. After an episode of rheumatic fever, long-term antibiotics prevent further strep infections; the WHO says the most effective option is benzathine penicillin G given by intramuscular injection every 3 to 4 weeks over many years. Healthdirect stresses that these injections should never be missed or stopped without talking to a doctor. The length and exact schedule are set by the treating clinician.

Healthdirect adds that medicines may be used to regulate heartbeat, manage fluid and prevent clots on damaged valves, and that surgery may repair or replace valves. Surgery controls symptoms but does not cure the disease. Where valve damage is severe enough to weaken the heart, heart failure can follow.

In 2018 the World Health Assembly adopted resolution WHA71.14, which, in the WHO's words, called for a coordinated global response to rheumatic heart disease and rheumatic fever. The WHO also refers to its 2024 guidelines on prevention and diagnosis of the two conditions.

The NHS advises seeing a doctor if someone has had rheumatic fever before and gets a sore throat, thinks it has returned, or develops its symptoms after a recent bacterial throat infection. Anyone with breathlessness, chest pain, swelling or palpitations should have them checked. Severe breathing difficulty or sudden chest pain needs emergency care; emergency numbers differ by country, so use your local emergency number.

Rheumatic heart disease is valve scarring that follows rheumatic fever, itself a delayed reaction to group A strep infection. It affects young people most and is concentrated in low- and middle-income settings. It can be silent at first, is confirmed with an echocardiogram, and long-term penicillin prevention supervised by a clinician helps protect the valves from further damage.