The outcome has a wide range of possibilities - from total recovery (with risk of recurrences) to death due to cardiac failure. In between there are various kinds of chronic RHD. Death during 1st attack is rare. The chances are higher during recurrence especially in patients with pre-existing heart involvement. If heart is spared in the first attack, it is likely to be spared in subsequent occurrences too. Patients with no carditis have the best prognosis. Chorea and arthritis by themselves are benign. Patients with chorea may develop heart disease years after the attack of chorea. Recurrence with pre-existing heart involvement worsens the cardiac status by involving additional valves and development of refractory heart failure

I. Clinical evidence of cardiac involvement may disappear in the following conditions:

• In cases of questionable carditis in acute attack with mitral systolic murmur and no cardiomegaly.
  
  
• In definite single valve (mostly mitral) involvement without cardiomegaly. 58-74% lose evidence of cardiac involvement.
  
  
• Disappearance is less common in those with multiple valve involvement. Loss of evidence of mitral valve involvement may occur but aortic valve involvement persists.
  
  
• It is very rare in those with marked cardiomegaly and CCF.
  
  

II. Structural abnormality of the valve and chamber dilatation or hypertrophy may progress in the absence of recurrences.

III. Patients with AR may remain asymptomatic for years but when symptoms develop they progress rapidly.

IV. Mitral stenosis is rare during 1st attack . It develops early, within one year in developing countries but takes many years to develop in the Western world.

V. Chances of recurrence are more after the initial attack and lessen as time passes. (from 50% within 6 months to only 10% after 5 years.)

VI. Additional risk factors for recurrence are:

• Pre-existing acquired heart disease
  
  
• Vigor of antibody response to streptococcal antigen
  
  
• Severity of streptococcal infection