Rheumatic heart disease (RHD) remains a major global cause of cardiovascular death, and recent trials have sharpened both prevention and anticoagulation. The landmark GOAL trial showed that secondary antibiotic prophylaxis with intramuscular benzathine penicillin G every four weeks significantly reduced echocardiographic progression of latent (screening-detected) RHD in children and adolescents (progression 0.8% vs 2.8%) — supporting early detection and prophylaxis, albeit with a low screening yield. For anticoagulation in RHD-associated atrial fibrillation, the INVICTUS trial delivered an important negative result for DOACs: vitamin K antagonists were superior to rivaroxaban in reducing stroke, systemic embolism, MI, or vascular death, without more major bleeding — confirming that VKAs remain the standard and that rivaroxaban should not be used in this population. Emerging directions include longer-acting penicillin formulations and group A streptococcal vaccines, with benzathine penicillin remaining the cornerstone of secondary prevention.
Further reading: GOAL trial of secondary prophylaxis for latent RHD (Beaton et al., NEJM 2022); INVICTUS rivaroxaban in RHD-associated AF (Connolly et al., NEJM 2022); 2020 AHA RHD scientific statement (Kumar et al.).