Penicillin Reactions in Patients With Severe Rheumatic Heart Disease: A Presidential Advisory From the American Heart Association

Abstract

Secondary antibiotic prophylaxis with regular intramuscular benzathine penicillin G (BPG) is the cornerstone of rheumatic heart disease management. However, there is a growing body of evidence that patients with rheumatic heart disease who have severe valvular heart disease with or without reduced ventricular function may be dying from cardiovascular compromise following BPG injections. This advisory responds to these concerns and is intended to: (1) raise awareness, (2) provide risk stratification, and (3) provide strategies for risk reduction. Based on available evidence and expert opinion, we have divided patients into low‐ and elevated‐risk groups, based on symptoms and the severity of underlying heart disease. Patients with elevated risk include those with severe mitral stenosis, aortic stenosis, and aortic insuffiency; those with decreased left ventricular systolic dysfunction; and those with no symptoms. For these patients, we believe the risk of adverse reaction to BPG, specifically cardiovascular compromise, may outweigh its theoretical benefit. For patients with elevated risk, we newly advise that oral prophylaxis should be strongly considered. In addition, we advocate for a multifaceted strategy for vasovagal risk reduction in all patients with rheumatic heart disease receiving BPG. As current guidelines recommend, all low‐risk patients without a history of penicillin allergy or anaphylaxis should continue to be prescribed BPG for secondary antibiotic prophylaxis. We publish this advisory in the hopes of saving lives and avoiding events that can have devastating effects on patient and clinician confidence in BPG.

Lack of awareness of secondary rheumatic prevention in preoperative candidates for mitral valve surgery – alarming situation

“…27 However, it is also important to be aware of possible complications that may follow the Benzathine Penicillin injection such as cardiovascular compromise or spinal cord injury and such adverse reaction may outweigh the theoretical benefit and in such patients oral prophylaxis should be strongly considered. 28,29 The main limitations of this study include a low sample size and the fact that it was conducted at a single-center public sector hospital, primarily involving patients from low-or middle-income groups. Therefore, it is important to acknowledge that the findings of this study cannot be generalized to the entire population.…”

“…27 However, it is also important to be aware of possible complications that may follow the Benzathine Penicillin injection such as cardiovascular compromise or spinal cord injury and such adverse reaction may outweigh the theoretical benefit and in such patients oral prophylaxis should be strongly considered. 28,29…”

Evaluating the implementation of a dynamic digital application to enable community-based decentralisation of rheumatic heart disease case management in Uganda: protocol for a hybrid type III effectiveness-implementation study

“…Registrants will be ineligible for participation if they have severe RHD—shown to be associated with an increased risk of a vasovagal mediated sudden deterioration during or immediately after a BPG injection; caution has been issued on BPG use in this population. 34 According to these recommendations, we will exclude patients with severe mitral stenosis, severe aortic regurgitation or stenosis, ventricular dysfunction (Measured ejection fraction (EF) <50%) or with advanced symptoms (New York Heat Association (NYHA) class III/IV) 34 as ascertained by echocardiography performed within 6 months prior to decentralisation.…”

Tertiary prevention and treatment of rheumatic heart disease: a National Heart, Lung, and Blood Institute working group summary

“…In practice, monthly injections have been used to simplify the regimen and promote better adherence in patients with low health literacy and socioeconomic constraints, despite lack of strong evidence to support this approach. Patients should be divided into low-risk and elevated-risk groups, based on symptoms and the severity of underlying heart disease, and those with elevated risk (severe mitral stenosis, aortic stenosis and aortic insufficiency), decreased left ventricular systolic dysfunction, and no symptoms, should be considered for oral prophylaxis 39. In addition, multifaceted strategies for vasovagal risk reduction during BPG injections have been suggested, but no consensus guidelines have been widely adopted.…”