IJCS | Volume 31, Nº6, November / December 2018

579 Lemos et al. Evolutive study of rheumatic carditis cases Int J Cardiovasc Sci. 2018;31(6)578-584 Original Article practitioners and the population in general about the importance of prevention and early diagnosis of this disease. 1 However, secondary prophylaxis is prone to failure, due to poor treatment compliance by patients 9 and/or gaps in nationwide antibiotic distribution networks, particularly Penicillin GBenzathine, breaching the directive issued by this MH that ensures no-cost distribution of this medication. 10 Due to the importance of this issue, we decided to evaluate the cases of rheumatic carditis in individuals under 18 years of age treated with corticotherapy, in a public hospital in Rio de Janeiro State, and to verify the results obtained in the long-term follow-up. Methods An observational, longitudinal and retrospective study was carried out in patients treated in the pediatric cardiology department of a tertiary hospital in the city of Rio de Janeiro, Rio de Janeiro State, Brazil, for 15 years (2000–2015). All cases had the RF diagnosis made according to the reviewed and revalidated Jones criteria, plus evidence of prior pharyngotonsillitis caused by Lancefield’s group A beta-hemolytic Streptococcus (GABHS). 1,11,12 The inclusion criteria were: children and adolescents between 5 and 18 years of age undergoing corticoid treatment. The treatment followed the guidelines issued by the World Health Organization (WHO) and the Brazilian Cardiology Society (SBC). 1,2,13 Corticoid treatment consisted of oral Prednisone, given as a single daily dose of 1 to 2 mg/kg/day (milligrams per kilogram per day), for eight weeks in cases of mild carditis or nine to 11 weeks in cases of moderate and severe carditis. 1,2 The full dose was given for approximately three weeks, tapering off by 20 to 25% of the initial dose each week, in response to clinical and laboratory improvement. 1 Pulse therapy involved the administration of venous Methylprednisolone, at doses of 30 mg/kg/day, 1,14,15 for two weeks, with each cycle lasting three days, for severe carditis or when emergency surgery was required. 1,16 Immunosuppression was then completed with full-dose oral corticoids. Streptococcus eradication required the administration of a single dose of 1,200,000 IU (International Units) of Penicillin G Benzathine through deep intramuscular injection, for patients weighing 20 kg (kilograms) or more and 600,000 IU for those weighing less than 20 kg. The oral medication used was Penicillin V, at a dose of 50,000 IU/kg/day (International Units per kilogram per day) every eight hours, for 10 days. As an option, treatment in some cases consisted of Amoxicillin at a dose of 50 mg/ kg/day every eight hours, for 10 days. 1 Secondary prophylaxis, with Penicillin G Benzathine, began while patients were still hospitalized and continued after their release, with outpatient control, prescribed at the same doses and with an interval of 21 days. 1,12,17 Some cases were treated with oral antibiotics, by administering 400,000 IU of Penicillin V every 12 hours; or daily Sulfadiazine at a dose of 500 mg for patients weighing less than 30 kg and 1 g (gram) for those weighing 30 kg or more; 1,18,19 or 250 mg of Erythromycin every 12 hours. 1,19 Based on their clinical evolution, patients were divided into two groups: A – cases treated only with corticosteroids at immunosuppressive doses; B – cases that also required surgery. Statistical analysis The Stata program version 13.0 ( Stata Corp ) was used. The level of statistical significance was set at 5% (p < 0.05) as the statistically significant difference for all analyses. The Shapiro-Wilk’s test was used to test the normality of the variables. Continuous variables with normal distribution were represented by mean and standard deviation and, otherwise, by median and interquartile range. The 95% confidence intervals were calculated, and the chi-square test was applied for the difference between proportions. Wilcoxon’s test was used to compare left ventricular ejection fraction (LVEF) before and after treatment. Ethical aspects This research was approved by the Research Ethics Committee (REC) of the institute – National Research Ethics Commission (CONEP) and obtained a CAAE registration number: 21608213.0.0000.5265, available at the following website: http://www.saude.gov.br/ plataformabrasil. As a retrospective study, there was no need to obtain the Free and Informed Consent form. Results The number of diagnosed cases of RF treated at the institute between January 2000 and December 2015 included 174 patients. We selected 93 of them that required immunosuppression with corticosteroids.