MioAtlas
G7: Infections and inflammation

Acute rheumatic carditis

Acute inflammatory manifestations of rheumatic fever on cardiac structures, characterized by active valvulitis (predominantly mitral), myocarditis, and variable degrees of pericarditis (rheumatic pancarditis).

Open in 3D simulator

Definition

Active inflammatory manifestations of rheumatic fever on cardiac structures, characterized by active valvulitis (predominantly mitral), myocarditis, and variable degrees of pericarditis (rheumatic pancarditis), triggered as an autoimmune cross-reactive response following group A beta-hemolytic Streptococcus pyogenes pharyngitis [G7-01] [G7-10].

Severity criteria

  • Severity grade: Single grade. Represents the florid presentation of active rheumatic pancarditis according to the revised Jones Criteria of the AHA 2015 [G7-01, Tabla 1 y 2] and the review by Marijon et al. [G7-10].
  • Revised Jones diagnostic criteria (AHA 2015 [G7-01]):
    • Major Criterion: Clinical or subclinical carditis diagnosed by Doppler echocardiography with morphological and hemodynamic confirmation of mitral (and/or aortic) valvulitis: pathological mitral regurgitation demonstrable in at least 2 Doppler planes with jet length ≥ 2.0 cm, peak velocity > 3.0 m/s, and EROA ≥ 0.20–0.35 cm² (RV ≥ 30–50 mL/beat).
    • Minor electrocardiographic criterion: Prolonged PR interval for age (PR > 200 ms in adults or > 160–180 ms in children) [G7-01].
  • Morphological criteria for acute mitral valvulitis: Nodular thickening or beading of mitral leaflet tips and free edges (thickness ≥ 3–4 mm in acute exudative phase), associated with anterior leaflet prolapse or restricted coaptation [G7-01].

Findings by layer

Hemodynamics

  • Pulmonary capillary wedge pressure / left atrium: Moderately elevated (12–18 mmHg) due to acute mitral regurgitation [G7-01] [V3].
  • Systemic cardiac output: Preserved or slightly reduced in case of associated inflammatory myocardial dysfunction.

Rhythm

  • Characteristic rhythm: First-degree atrioventricular block (first-degree AV block), consequence of conduction delay in the AV node caused by focal inflammation or vagal tone mediated by the systemic rheumatic process [G7-01] [G7-10].

ECG

  • PR interval prolongation (PR interval > 200 ms / first-degree AV block) [G7-01] [E2].
  • Baseline sinus tachycardia disproportionate to body temperature [G7-01].
  • Possible diffuse concave ST elevation or T-wave flattening if serofibrinous pericarditis coexists [C2].

Heart sounds and murmurs

  • Holosystolic mitral regurgitation murmur: High-frequency apical pansystolic blowing or musical murmur radiating to the axilla, originating from mitral valvulitis [G7-01] [G7-10] [B1].
  • Carey Coombs murmur: Short, low-pitched, soft apical mid-diastolic murmur (audible with stethoscope bell at the apex in left lateral decubitus), due to filling turbulence across an edematous, inflamed mitral valve with relative volume hyperflow from prior regurgitation [G7-10] [G7-01].
  • Pericardial friction rub: Superficial, harsh triphasic or biphasic rub auscultated in mesocardium/left sternal border when concomitant pericardial involvement is present [G7-10] [C2].
  • Third heart sound (S3): Present at the apex due to rapid ventricular diastolic filling in the presence of moderate mitral regurgitation [B1].

Arterial pulse

  • Rapid and bounding peripheral pulse [B4].

Jugular venous pulse

  • Generally normal or with slight elevation of central venous pressure in florid pericarditis or myocarditis [B3].

Maneuvers

  • Isometric handgrip: Increases the intensity of the holosystolic mitral regurgitation murmur [B1].
  • Left lateral decubitus in expiration: Optimizes acoustic detection of the Carey Coombs mid-diastolic murmur at the mitral area [G7-10] [B1].
  • Leaning forward: Favors auscultation of pericardial friction rub [C2] [B1].

Simulator severity grades

Simulator severity grades: Single grade
Baseline rhythm: First-Degree AV Block

Also known as: Acute rheumatic carditis · Rheumatic pancarditis · Acute rheumatic fever carditis · Rheumatic carditis · Rheumatic heart disease

Other pathologies in this group

Sources

  1. [B1] Bedside diagnosis of systolic murmurs . N Engl J Med (1988) . DOI: 10.1056/NEJM198806163182404 PubMed: 2897627
  2. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  3. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  4. [C2] 2025 ESC Guidelines for the management of myocarditis and pericarditis . Eur Heart J (2025) . DOI: 10.1093/eurheartj/ehaf192 PubMed: 40878297
  5. [E2] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191095 PubMed: 19228822
  6. [G7-01] Revision of the Jones Criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography: a scientific statement from the American Heart Association . Circulation (2015) . DOI: 10.1161/CIR.0000000000000205 PubMed: 25908771
  7. [G7-10] Rheumatic heart disease . Lancet (2012) . DOI: 10.1016/S0140-6736(11)61171-9 PubMed: 22405798
  8. [V1] 2025 ESC/EACTS Guidelines for the management of valvular heart disease . Eur Heart J (2025) . DOI: 10.1093/eurheartj/ehaf194 PubMed: 40878295
  9. [V3] Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance . J Am Soc Echocardiogr (2017) . DOI: 10.1016/j.echo.2017.01.007 PubMed: 28314623