Presidential Advisory Recommends Penicillin Treatments for Children with Mild Rheumatic Heart Disease, Cautions Treatment for Patients with Severe Disease
A new presidential advisory from the American Heart Association that includes Dr. Sable as an author, provides new insights into very rare, but serious adverse reactions to Penicillin in patients with rheumatic heart disease. Penicillin shots have been shown to slow the progression of RHD. RHD affects 40.5 million people globally and results in over 306,000 annual deaths.
Despite proven safety and effectiveness, a small number of life-threatening reactions around the globe make some patients, parents, doctors and nurses reluctant to receive or give Penicillin shots. This is because reactions were felt to be allergic and random – they could happen to anyone. The advisory changes our thinking; these reactions are usually limited to those with severe heart valve disease, related to abnormal blood flow from the sick heart and not an allergic reaction.
While more research is needed, the advisory urges caution against using injectable penicillin to treat a small number of patients with very severe RHD. However, the advisory also explains that severe reactions are likely very limited, clearing the way for patients with early or mild disease to continue being treated with penicillin shots.
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 (benzathine penicillin G), 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.
A report published in November 2021 in The New England Journal of Medicine, which our team was proud to be a part of, proved that penicillin, which is widely available and affordable, works to prevent the progression of early echo detected Rheumatic Heart Disease.
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