Top Things to Know: Penicillin Reactions in Patients With Severe Rheumatic Heart Disease
Published: January 20, 2022
- Over 39 million people suffer from rheumatic heart disease (RHD). The vast majority live in low- and middle-income countries. In these settings, RHD is often diagnosed late, after severe valvular heart disease or cardiovascular (CV) complications have already developed.
- Secondary antibiotic prophylaxis with injectable Benzathine Penicillin G (BPG), given via intramuscular injection every three to four weeks for a prolonged period is the cornerstone of RHD prevention and management. However, adoption of BPG has been sub-optimal. Poor uptake is multifactorial, but fear of anaphylaxis and subsequent death causes some patients to resist receiving injections and healthcare workers to resist administering them. The true risk of anaphylaxis following a BPG injection, however, is low.
- There is a growing body of evidence that some patients with RHD and severe valvular heart disease (VHD) and/or reduced ventricular function could be dying from CV compromise following BPG injections rather than anaphylactic reactions as previously thought.
- This advisory is urgently needed to raise awareness, provide risk stratification, and to give guidance on easily implementable protocols to reduce risk and overcome reluctance to administer and receive secondary prophylaxis with BPG penicillin around the world.
- While the mechanisms vary slightly based on the distribution of underlying structural heart disease, it is postulated that pain and/or fear of BPG administration drives a physiological response precipitating decompensation that may include vasovagal hypotension, bradycardia, and syncope, leading to decreased coronary perfusion, ventricular arrhythmias and sudden cardiac death.
- The most important factor predisposing patients to cardiac compromise appears to be the severity of the underlying VHD. Patients with severe VHD, regardless of the valve in question, have little CV reserve and may not compensate well to pain on injection or vasovagal syncope associated with administration of BPG.
- Elevated risk patients include those with severe mitral stenosis, aortic stenosis, and aortic insufficiency, decreased left ventricular systolic function (ejection fraction < 50%), and symptomatic patients. For these patients, the risk of adverse reaction to BPG, specifically CV compromise, may outweigh its theoretical benefit.
- For patients with elevated risk, oral prophylaxis should be strongly considered.
- A multifaceted strategy is important for vasovagal risk reduction in all RHD patients receiving BPG, including reducing pain and anxiety, adequate hydration and food intake prior to injection, and, when feasible, administration of BPG while in the supine position. In addition, education should be provided for those who administer BPG regarding the recognition of vasovagal symptoms, as well as the importance of teaching their patients as appropriate.
- As current guidelines recommend, all low-risk patients without history of penicillin allergy or anaphylaxis should be prescribed BPG for secondary prophylaxis given its superior efficacy in the prevention of recurrent rheumatic fever.
Citation
Sanyahumbi A, Ali S, Benjamin IJ, Karthikeyan G, Okello E, Sable CA, Taubert K, Wyber R, Zuhlke L, Carapetis JR, Beaton AZ; on behalf of the American Heart Association. Penicillin reactions in patients with severe rheumatic heart disease: a presidential advisory from the American Heart Association. J Am Heart Assoc. 2021;10:e024517. doi: 10.1161/JAHA.121.024517