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OUR MISSION: TO REDUCE THE BURDEN OF CARDIOVASCULAR DISEASE
Prof. Gilbert Habib,
Infective endocarditis (IE) is a severe form of valve disease characterized by infection located on the valves of the heart. It is still associated with a high mortality (10-26% in-hospital mortality). IE is a rare disease, with reported incidences ranging from 3 to 10 episodes/100,000 people per year.
From an epidemiological point of view, IE has changed over the last few years, with newer predisposing factors – valve prostheses, degenerative valve sclerosis, intravenous drug abuse (IVDA), associated with the increased use of invasive procedures at risk for bacteremia, while rheumatic disease has nearly disappeared. Health care-associated IE (meaning IE caused by in-hospital contamination) represents up to 30% cases of IE.
One of the main changes in new guidelines is the proposed reduction of prophylaxis, because there is no real scientific proof of its efficacy, and it may be potentially dangerous. Thus, antibiotic prophylaxis is now recommended only for patients with the highest risk of IE undergoing the highest risk dental procedures. Prophylaxis is no longer recommended in the majority of acquired valvular valve disease. Good oral hygiene and regular dental review have a very important role in reducing the risk of IE.
Quick identification of patients at highest risk of death may offer the opportunity to change the course of the disease and improve prognosis. It will also allow identification of patients with the worst immediate outcome who will benefit from closer follow-up and a more aggressive treatment strategy. Prognostic assessment at admission can be performed using simple clinical, microbiological, and echocardiographic parameters, and should be used to choose the best therapeutic option.
The treatment of IE relies on the combination of prolonged antimicrobial therapy and - in about half of patients - surgical eradication of the infected tissues. The new guidelines focus on the 3 main indications for surgery- heart failure (HF), uncontrolled infection, and prevention of embolic events. Moreover, for the first time, the guidelines give indications concerning the optimal timing of surgery.
The main take-home message is that surgery must be performed safely earlier during the course of the disease, and that valve repair can be performed in the majority of patients, giving better results that conventional valve replacement.
Endocarditis: changing guidelines for a changing disease
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