Endocarditis natural history, complications and prognosis: Difference between revisions

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==Overview==
==Overview==
If left untreated, patients with endocarditis may progress to develop [[congestive heart failure]].  [[Endocarditis complications|Complications of endocarditis]] can occur as a result of the locally destructive effects of the infection. These complications include perforation of valve leaflets causing [[congestive heart failure]], [[abscesses]], and disruption of the heart's conduction system.  Endocarditis may also cause embolization to the brain (causing a [[stroke]]), to the [[coronary artery]] (causing a [[heart attack]]), to the [[lung]] (causing [[pulmonary embolism]]), to the [[spleen]] (causing a splenic infarct), and to the [[kidney]] (causing a [[renal infarct]]).  Prognosis of endocarditis is generally poor and the overall mortality rate for both native and prosthetic valve endocarditis ranges from 20-25%.  The mortality rate for right-sided endocarditis in injection drug users is approximately 10%. The 5-year survival rate for [[endocarditis|native valve endocarditis]] is 70-80% and 50-80%  for [[endocarditis|prosthetic valve endocarditis]].
If left untreated, patients with [[endocarditis]] may progress to develop [[congestive heart failure]].  [[Endocarditis complications|Complications of endocarditis]] can occur as a result of the locally destructive effects of the infection. These [[complications]] include [[perforation]] of valve leaflets causing [[congestive heart failure]], [[abscesses]], and disruption of the heart's [[Conduction System|conduction]] system.  [[Endocarditis]] may also cause [[embolization]] to the brain (causing a [[stroke]]), to the [[coronary artery]] (causing a [[heart attack]]), to the [[lung]] (causing [[pulmonary embolism]]), to the [[spleen]] (causing a [[splenic]] [[infarct]]), and to the [[kidney]] (causing a [[renal infarct]]).  [[Prognosis]] of [[endocarditis]] is generally poor and the overall mortality rate for both native and [[prosthetic]] valve [[endocarditis]] ranges from 20-25%.  The [[mortality rate]] for right-sided [[endocarditis]] in injection drug users is approximately 10%. The 5-year survival rate for [[endocarditis|native valve endocarditis]] is 70-80% and 50-80%  for [[endocarditis|prosthetic valve endocarditis]].


==Natural History==
==Natural History==


* If left untreated, patients with endocarditis may progress to develop [[congestive heart failure]].<ref name="pmid11794152">{{cite journal| author=Mylonakis E, Calderwood SB| title=Infective endocarditis in adults. | journal=N Engl J Med | year= 2001 | volume= 345 | issue= 18 | pages= 1318-30 | pmid=11794152 | doi=10.1056/NEJMra010082 | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11794152  }} </ref>
* If left untreated, patients with [[endocarditis]] may progress to develop [[congestive heart failure]].<ref name="pmid11794152">{{cite journal| author=Mylonakis E, Calderwood SB| title=Infective endocarditis in adults. | journal=N Engl J Med | year= 2001 | volume= 345 | issue= 18 | pages= 1318-30 | pmid=11794152 | doi=10.1056/NEJMra010082 | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11794152  }} </ref>


==Complications==
==Complications==
Complications of infective endocarditis include:<ref name="pmid11794152">{{cite journal| author=Mylonakis E, Calderwood SB| title=Infective endocarditis in adults. | journal=N Engl J Med | year= 2001 | volume= 345 | issue= 18 | pages= 1318-30 | pmid=11794152 | doi=10.1056/NEJMra010082 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11794152  }} </ref><ref name="Baddour">{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F.,  Levison Matthew E.,  Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato,  Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>
[[Complications]] of infective [[endocarditis]] include:<ref name="pmid11794152">{{cite journal| author=Mylonakis E, Calderwood SB| title=Infective endocarditis in adults. | journal=N Engl J Med | year= 2001 | volume= 345 | issue= 18 | pages= 1318-30 | pmid=11794152 | doi=10.1056/NEJMra010082 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11794152  }} </ref><ref name="Baddour">{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F.,  Levison Matthew E.,  Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato,  Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>
===Cardiac===
===Cardiac===
# [[Murmur]]  
# [[Murmur]]  
# A new aortic [[diastolic murmur]] suggests dilatation of the aortic annulus or eversion, rupture, or fenestration of an aortic leaflet
# A new aortic [[diastolic murmur]] suggests dilatation of the aortic annulus or [[eversion]], rupture, or [[fenestration]] of an aortic leaflet
# The sudden onset of a loud mitral pansystolic murmur suggests rupture of chorda tendineae or fenestration of a [[mitral valve]] leaflet
# The sudden onset of a loud [[mitral]] pansystolic [[murmur]] suggests rupture of [[chordae tendineae]] or [[fenestration]] of a [[mitral valve]] leaflet
# [[Congestive heart failure]]  
# [[Congestive heart failure]]  
# [[Arrhythmias|Cardiac rhythm disturbances]] including [[AV block]]
# [[Arrhythmias|Cardiac rhythm disturbances]] including [[AV block]]
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# [[Petechiae]] of the [[conjunctiva]], [[oropharynx]], [[skin]], and legs
# [[Petechiae]] of the [[conjunctiva]], [[oropharynx]], [[skin]], and legs
# Linear subungual [[splinter haemorrhage]]s of the lower or middle nail bed
# Linear subungual [[splinter haemorrhage]]s of the lower or middle nail bed
# [[Osler’s nodes]]
#[[Osler's nodes]]
# [[Janeway lesion]]s
# [[Janeway lesion]]s


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===Ocular===
===Ocular===
# Petechial hemorrhages
#[[Petechia|Petechial]] [[hemorrhages]]
# Flame-shaped hemorrhages
# Flame-shaped [[hemorrhages]]
# [[Roth's spot]]s  
# [[Roth's spot]]s  
# Cotton-wool exudates in the [[retina]]
#[[Cotton-wool spot|Cotton-wool]] exudates in the [[retina]]


===Embolic===
===Embolic===
# Significant [[emboli|arterial emboli]] occur in 30%–50% of patients, causing the following:  
# Significant [[emboli|arterial emboli]] occur in 30%–50% of patients, causing the following:  
#* [[Stroke]]  
#*[[Stroke]]
#* [[blindness|Monocular blindness]]  
#* [[blindness|Monocular blindness]]  
#* [[abdominal pain|Acute abdominal pain]], [[ileus]], and [[melena]]  
#* [[abdominal pain|Acute abdominal pain]], [[ileus]], and [[melena]]  
#* [[Pain]] and [[gangrene]] in the extremities
#* [[Pain]] and [[gangrene]] in the [[extremities]]
# [[emboli|CNS emboli]] are common  
# [[emboli|CNS emboli]] are common  
# [[emboli|Coronary emboli]], often asymptomatic, can cause [[myocardial infarction]]  
# [[emboli|Coronary emboli]], often [[asymptomatic]], can cause [[myocardial infarction]]
# [[Pulmonary emboli]] are common in right-sided [[endocarditis]], causing pulmonary infarcts or focal [[pneumonitis]]
# [[Pulmonary emboli]] are common in right-sided [[endocarditis]], causing [[pulmonary]] infarcts or focal [[pneumonitis]]


===Splenic===
===Splenic===
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===Renal===
===Renal===
# [[hematuria|Microscopic hematuria]] occurs in ~ 50% of patients  
# [[hematuria|Microscopic hematuria]] occurs in ~ 50% of patients  
# Embolic [[renal infarction]]  
#[[Embolic]] [[renal infarction]]
# [[membranoproliferative glomerulonephritis|Diffuse membranoproliferative glomerulonephritis]]  
# [[membranoproliferative glomerulonephritis|Diffuse membranoproliferative glomerulonephritis]]  


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===Neurologic===
===Neurologic===
# Neurologic complications occur in 25%–40% of cases  
#[[Neurology|Neurologic]] [[complications]] occur in 25%–40% of cases
# [[Stroke]]s caused by cerebral embolisms in ~15% of cases, causing the following:  
# [[Stroke]]s caused by cerebral embolisms in ~15% of cases, causing the following:  
#:*[[consciousness|Altered level of consciousness]]  
#:*[[consciousness|Altered level of consciousness]]
#:*[[Seizures]]  
#:*[[Seizures]]  
#:*Fluctuating focal neurologic signs
#:*Fluctuating focal [[neurologic]] signs
# Cerebral aneurysms occur in 1%–5% of cases, causing the following:  
#[[Cerebral]] [[Aneurysm|aneurysms]] occur in 1%–5% of cases, causing the following:  
#:*[[Headache]]  
#:*[[Headache]]
#:*Focal signs  
#:*Focal signs  
#:*Acute [[intracerebral hemorrhage|intracerebral]] or [[subarachnoid hemorrhage]] caused by rupture  
#:*Acute [[intracerebral hemorrhage|intracerebral]] or [[subarachnoid hemorrhage]] caused by rupture  
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===Monitoring for Complications of Infectious Endocarditis===
===Monitoring for Complications of Infectious Endocarditis===
Among those patients at high risk, careful monitoring should be undertaken to detect the early development of complications such as:
Among those patients at high risk, careful monitoring should be undertaken to detect the early development of [[complications]] such as:


# Valvular dysfunction, usual insufficiency of the mitral or aortic valves  
#[[Valvular]] dysfunction, usual insufficiency of the [[mitral]] or [[aortic]] [[valves]]
# Myocardial or septal [[abscess]]es
#[[Myocardial]] or septal [[abscess]]es
# [[Congestive heart failure]]
# [[Congestive heart failure]]
# Metastatic infection
#[[Metastatic]] infection
# Embolic phenomenon
#[[Embolic]] phenomenon


==Prognosis==
==Prognosis==


* The prognosis of endocarditis is generally poor and the overall mortality rate for both native and prosthetic valve endocarditis ranges from 20-25%.
* The [[prognosis]] of [[endocarditis]] is generally poor and the overall mortality rate for both native and [[prosthetic]] valve [[endocarditis]] ranges from 20-25%.
* The mortality rate for right-sided endocarditis in injection drug users is approximately 10%.<ref name="pmid11794152">{{cite journal| author=Mylonakis E, Calderwood SB| title=Infective endocarditis in adults. | journal=N Engl J Med | year= 2001 | volume= 345 | issue= 18 | pages= 1318-30 | pmid=11794152 | doi=10.1056/NEJMra010082 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11794152  }} </ref>  
* The mortality rate for right-sided [[endocarditis]] in injection drug users is approximately 10%.<ref name="pmid11794152">{{cite journal| author=Mylonakis E, Calderwood SB| title=Infective endocarditis in adults. | journal=N Engl J Med | year= 2001 | volume= 345 | issue= 18 | pages= 1318-30 | pmid=11794152 | doi=10.1056/NEJMra010082 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11794152  }} </ref>
* The 5-year survival rate for [[endocarditis|native valve endocarditis]] is 70-80% and 50-80%  for [[endocarditis|prosthetic valve endocarditis]].<ref name="Baddour">{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F.,  Levison Matthew E.,  Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato,  Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>
* The 5-year survival rate for [[endocarditis|native valve endocarditis]] is 70-80% and 50-80%  for [[endocarditis|prosthetic valve endocarditis]].<ref name="Baddour">{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F.,  Levison Matthew E.,  Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato,  Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>


Latest revision as of 01:56, 6 March 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maliha Shakil, M.D. [2]

Overview

If left untreated, patients with endocarditis may progress to develop congestive heart failure. Complications of endocarditis can occur as a result of the locally destructive effects of the infection. These complications include perforation of valve leaflets causing congestive heart failure, abscesses, and disruption of the heart's conduction system. Endocarditis may also cause embolization to the brain (causing a stroke), to the coronary artery (causing a heart attack), to the lung (causing pulmonary embolism), to the spleen (causing a splenic infarct), and to the kidney (causing a renal infarct). Prognosis of endocarditis is generally poor and the overall mortality rate for both native and prosthetic valve endocarditis ranges from 20-25%. The mortality rate for right-sided endocarditis in injection drug users is approximately 10%. The 5-year survival rate for native valve endocarditis is 70-80% and 50-80% for prosthetic valve endocarditis.

Natural History

Complications

Complications of infective endocarditis include:[1][2]

Cardiac

  1. Murmur
  2. A new aortic diastolic murmur suggests dilatation of the aortic annulus or eversion, rupture, or fenestration of an aortic leaflet
  3. The sudden onset of a loud mitral pansystolic murmur suggests rupture of chordae tendineae or fenestration of a mitral valve leaflet
  4. Congestive heart failure
  5. Cardiac rhythm disturbances including AV block
  6. Pericarditis (uncommon)

Cutaneous

  1. Petechiae of the conjunctiva, oropharynx, skin, and legs
  2. Linear subungual splinter haemorrhages of the lower or middle nail bed
  3. Osler's nodes
  4. Janeway lesions

Musculoskeletal

  1. Myalgias
  2. Arthralgias
  3. Arthritis
  4. Low back pain
  5. Rheumatoid factor is elevated in up to 50% of patients with endocarditis for >6 weeks
  6. Clubbing of fingers is present in < 15% of patients

Ocular

  1. Petechial hemorrhages
  2. Flame-shaped hemorrhages
  3. Roth's spots
  4. Cotton-wool exudates in the retina

Embolic

  1. Significant arterial emboli occur in 30%–50% of patients, causing the following:
  2. CNS emboli are common
  3. Coronary emboli, often asymptomatic, can cause myocardial infarction
  4. Pulmonary emboli are common in right-sided endocarditis, causing pulmonary infarcts or focal pneumonitis

Splenic

  1. Splenomegaly is observed in 15%–30% of patients
  2. Splenic infarcts occur in up to 40% of patients
  3. Splenic abscesses occur in ~ 5% of patients

Renal

  1. Microscopic hematuria occurs in ~ 50% of patients
  2. Embolic renal infarction
  3. Diffuse membranoproliferative glomerulonephritis

Mycotic Aneurysms

Occur in any artery in 2%–8% of patients, causing the following:

  1. Pain or headache
  2. Pulsatile mass
  3. Fever
  4. Sudden expanding hematoma
  5. Signs of major blood loss

Neurologic

  1. Neurologic complications occur in 25%–40% of cases
  2. Strokes caused by cerebral embolisms in ~15% of cases, causing the following:
  3. Cerebral aneurysms occur in 1%–5% of cases, causing the following:
  4. Brain abscesses may occur in acute endocarditis caused by Staphylococcus aureus
  5. Seizures

Monitoring for Complications of Infectious Endocarditis

Among those patients at high risk, careful monitoring should be undertaken to detect the early development of complications such as:

  1. Valvular dysfunction, usual insufficiency of the mitral or aortic valves
  2. Myocardial or septal abscesses
  3. Congestive heart failure
  4. Metastatic infection
  5. Embolic phenomenon

Prognosis

References

  1. ↑ 1.0 1.1 1.2 Mylonakis E, Calderwood SB (2001). "Infective endocarditis in adults". N Engl J Med. 345 (18): 1318–30. doi:10.1056/NEJMra010082. PMID 11794152. Unknown parameter |http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom= ignored (help)
  2. ↑ 2.0 2.1 Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A. (2005). "Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): 3167–84. PMID 15956145.

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