Oral penicillin a better choice than injections for some patients with rheumatic heart disease
Oral penicillin may be a safer treatment option than injectable penicillin for certain high-risk patients with rheumatic heart disease (RHD), according to a new presidential advisory from the American Heart Association (AHA).
Intramuscular injections of benzathine penicillin G (BPG) is the standard treatment for RHD, but some patients have been having a severe allergic reaction known as anaphylaxis after treatment. According to the new advisory, these patients may actually be experiencing cardiac reactions to the medicine as opposed to normal allergic reactions. For this reason, the AHA is recommending oral penicillin for high-risk patients instead of intramuscular injections.
The advisory, published in full in the Journal of the American Heart Association, is the work of several specialists, including pediatric cardiologist Amy E. Sanyahumbi, MD, of Texas Children's Hospital in Houston.
“Until recently, deaths within the minutes and hours after BPG injection have been assumed to be due to anaphylaxis,” Sanyahumbi, chair of the presidential advisory writing group, said in a prepared statement. “However, a growing number of reports of BPG-related deaths did not have the features of classic anaphylaxis, and, instead, point to cardiovascular reactions. This distinction is important, as it indicates the need for different strategies to prevent or stop these reactions to BPG.”
Patients with severe mitral stenosis, aortic stenosis, aortic insufficiency or decreased left ventricular systolic function (ejection fraction less than 50%) may face an elevated risk of an adverse reaction to BPG, the group noted in its analysis. Patients presenting with active symptoms of RHD also fall into this category.
This shift to oral penicillin is not necessary for all patients, the researchers explained. It is still recommended that patients who face a low risk of a cardiovascular reaction and have no history of penicillin allergies or anaphylaxis be given BPG for the treatment and prevention of RHD.
The advisory also provides other ways that providers can avoid adverse reactions to BPG treatment. For example, reducing injection pain and patient anxiety, both common risk factors for injection-related fainting, can improve patient care. For pain reduction, the group suggested applying firm pressure to the site for 10 seconds, applying an ice pack or using medications such as acetaminophen or ibuprofen. In addition, patients should be drinking at least 500 ml of water prior to injection.
“This advisory is urgently needed to raise awareness, provide risk stratification and guide health care professionals on easily implementable protocols to reduce risk and overcome reluctance to administer and receive BPG treatment for rheumatic heart disease,” co-author Andrea Z. Beaton, MD, a pediatric cardiologist at Cincinnati Children’s Hospital, said in the same statement.
Read the full AHA presidential advisory here.