69 - Infective Endocarditis and Valvular Heart Disease

Abstract

Infectious endocarditis (IE) is more often caused by Staphylococcus species than Streptococcus, and increasingly occurs in elderly, recently hospitalized patients, those with prosthetic valves and intra-cardiac devices, and in patients who inject opioids. IE should be considered in any patient with a predisposing condition and fever. IE frequently presents with a complication, including heart failure, embolic stroke or osteomyelitis. As soon as IE is suspected, order the two key diagnostic tests: at least two sets of blood cultures (obtained before starting antibiotics) and transthoracic echocardiography. Empiric antimicrobial treatment for IE should include vancomycin; consultation with a cardiothoracic surgeon is recommended if there is a left-sided vegetation. Acute rheumatic fever is a delayed nonsuppurative complication of streptococcal pharyngitis characterized by arthritis, carditis, chorea, subcutaneous nodules, and erythema marginatum. In a patient with severe mitral stenosis, hypovolemia and tachycardia are poorly tolerated. “Slow and full” are appropriate goals. In patients with critical aortic stenosis, excessive preload reduction with vasodilators and diuretics is to be avoided. In patients with acute aortic insufficiency, classic physical findings may be absent. Medical stabilization entails the cautious use of vasodilators and diuretics. Intraaortic balloon counterpulsation is contraindicated. Complications of prosthetic heart valves range from structural failure and thrombosis to systemic embolization, hemolysis, and endocarditis.