Abstract: No new studies were included in this update. Eight randomised controlled trials involving 996 people were selected for inclusion in the review. Researchers compared several steroidal agents such as corticotrophin, cortisone, hydrocortisone, dexamethasone, prednisone and intravenous immunoglobulin versus aspirin, placebo or no treatment. Six trials were conducted between 1950 and 1965; one was done in 1990 and the final study was published in 2001. Overall there were no observed significant differences in risk of cardiac disease at one year between corticosteroid-treated and aspirin-treated groups (six studies, 907 participants, risk ratio 0.87, 95% confidence interval 0.66 to 1.15). Similarly, use of prednisone (two studies, 212 participants, risk ratio 1.13, 95% confidence interval 0.52 to 2.45) compared with aspirin did not reduce the risk of heart disease after one year. Investigators in five studies did not report adverse events. The three studies reporting on adverse events reported substantial adverse events. However, all results should be interpreted with caution because of the age of the studies and the substantial risk of bias. Little evidence of benefit was found when corticosteroids or intravenous immunoglobulins were used to reduce the risk of heart valve lesions in patients with acute rheumatic fever. The antiquity of most of the trials restricted adequate statistical analysis of the data and acceptable assessment of clinical outcomes by current standards. In addition, risk of bias was substantial, so results should be viewed with caution. New randomised controlled trials in patients with acute rheumatic fever are warranted to assess the effects of corticosteroids such as oral prednisone and intravenous methylprednisolone and the effects of other new anti-inflammatory agents. Advances in echocardiography will allow more objective and precise assessments of cardiac outcomes.

Plain-language summary: This is an update of a review published in 2003 and previously updated in 2009 and 2012. For this latest update, the search was rerun on 17 October 2013, and no new studies were found. Rheumatic fever is a late complication of a type of throat infection caused by streptococcal bacteria. It is an immune system disease that can lead to inflammatory disease of the heart (carditis), joints, brain and skin. Carditis can cause heart failure and death. Various anti-inflammatory drugs have been used to treat carditis, including corticosteroids, aspirin and immunoglobulins (immune therapy using antibodies). No new trials were identified in this update. This review includes eight trials with 996 participants. Evidence shows little effect of corticosteroids over aspirin in preventing cardiac disease after one year (six studies, 907 participants, risk ratio 0.87, 95% confidence interval 0.66 to 1.15). Several steroidal agents such as corticotrophin, cortisone, hydrocortisone and dexamethasone were compared with aspirin before 1966, and prednisone and immunoglobulins were compared with placebo in studies from 1990 and 2001, respectively. Most studies did not report on adverse events, but those that did reported complications due to corticosteroids including weight gain, enlarged facial features and acne. Trials were generally old (six of the eight trials were conducted between 1955 and 1965), small and of poor quality and had high risk of bias. For this reason, results should be interpreted with caution.