Prognosis

Acute recovery without treatment

Without treatment, the symptoms of acute rheumatic fever (ARF) usually resolve within several weeks, but unrecognised cardiac inflammation can last weeks to months and progress to rheumatic heart disease (RHD).

Acute recovery with treatment

With treatment, the symptoms of ARF usually resolve within several weeks, but cardiac inflammation lasts weeks to months. It is not uncommon for patients to have recurrent symptoms early after the first attack, particularly as they are weaned away from non-steroidal anti-inflammatory medication, salicylates, or glucocorticoids; this may include return of arthritis or arthralgia, with fever and elevated inflammatory markers. This does not indicate a recurrence, and can be managed with re-institution of anti-inflammatory medicine from which patients can be weaned at a slower pace.

Long-term sequelae

Patients with ARF should expect to make a complete recovery from the arthritis, fever, and chorea. Patients should be warned that, in the long term, they are at risk of repeated episodes of ARF and consequently of chronic RHD. The likelihood of developing RHD depends upon the severity of the initial attack of ARF and the number of recurrent episodes of rheumatic fever.[109] Around 30% to 50% of all patients with rheumatic fever will develop chronic RHD, and this risk increases to more than 70% if the initial attack is severe or if there has been at least one recurrence. Therefore, secondary prophylaxis to prevent recurrent attacks is very important, particularly as 75% of recurrences occur within 2 years of the first attack and more than 90% occur within the first 5 years. A first attack not involving the heart does not necessarily mean that subsequent attacks will also spare the heart.[64]​ The proportion of patients with a primary episode of ARF that develop a recurrence varies depending upon adherence with secondary prophylaxis; in areas where compliance is poor, up to 45% of cases of rheumatic fever are recurrent episodes. Conversely, in populations with excellent secondary prophylaxis delivery and adherence, recurrence rates are very low.[115]

Intramuscular benzathine benzylpenicillin reduces streptococcal pharyngitis by 71% to 91% and reduces recurrent rheumatic fever by 87% to 96%.[110] Secondary prophylaxis can reduce the clinical severity and mortality of RHD and lead to regression of RHD by about 50% to 70% if patients are adherent over a decade.[107][108]

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