Endocarditis infecciosa

 Abstract

Infective endocarditis (IE) remains a rare condition but one with high associated morbidity and mortality. With an ageing population and increasing use of implantable cardiac devices and heart valves, the epidemiology of IE has changed. Early clinical suspicion and a rapid diagnosis are essential to enable the correct treatment pathways to be accessed and to reduce complication and mortality rates. In the current review, we detail the latest guidelines for the evaluation and management of patients with endocarditis and its prevention.

Keywords: Infective endocarditis; antibiotic prophylaxis; diagnosis; endocarditis team; surgical indications.*1

Abstract 

Infective endocarditis (IE) is a life-threatening disease with an increasing incidence despite improved preventive measures. The revision of the European Society of Cardiology (ESC) guidelines on infective endocarditis in 2023 brings significant innovations in prevention, diagnostics, and treatment. Many measures for prophylaxis and prevention have been more clearly defined and given higher recommendation levels. In the diagnostics of IE the use of other imaging modalities besides echocardiography, such as cardiac computed tomography (CT), positron emission tomography (PET)/CT or single photon emission computed tomography (SPECT)/CT with radioactively labeled leukocytes was more strongly emphasized. The diagnostics and treatment of IE associated with a cardiac implantable electronic device (CIED) were also revised. An essential innovation is also the possibility of an outpatient antibiotic treatment for certain patients after initial treatment in hospital. The indications for surgery have also been revised and, in particular, the timing of surgery has been more clearly defined. This article provides an overview of the most important changes.

Keywords: Endocarditis/anti-bacterial agents; Endocarditis/prevention; Endocarditis/surgery; Guidelines; Tomography, X‑ray computed.*2

Abstract

In August 2023 the new European guidelines on the management of infective endocarditis were published by the European Society of Cardiology (ESC). Numerous recommendations were revised and supplemented by new ones. This review article outlines the essential modifications of the current ESC guidelines focusing on the prevention including antibiotic prophylaxis, the role of the endocarditis team, the revision of the diagnostic criteria, the paradigm shift towards oral antibiotic treatment, the timing and the indications for surgical treatment as well as the relevance of infections of cardiovascular implantable electronic devices.

Keywords: European Society of Cardiology; Guidelines; Infective endocarditis.*3

Abstract

Purpose of review: The question of antibiotic prophylaxis and its role in prevention of infective endocarditis (IE) remains controversial, with differing recommendations from international societies. The aim of this review was to compare and contrast current recommendations on antibiotic prophylaxis for IE by the American Heart Association (AHA), the European Society of Cardiology (ESC), and the National Institute for Health and Care Excellence (NICE) and highlight the evidence supporting these recommendations.

Recent findings: International guidelines for administration of antibiotic prophylaxis for prevention of IE are largely unchanged since 2009. Studies on the impact of the more restrictive antibiotic prophylaxis recommendations are conflicting, with several studies suggesting lack of adherence to current guidance from the ESC (2015), NICE (2016), and AHA (2021). The question of antibiotic prophylaxis in patients with IE remains controversial, with differing recommendations from international societies. Despite the change in guidelines more than 15 years ago, lack of adherence to current guidelines persists. Due to the lack of high-quality evidence and the conflicting results from observational studies along with the lack of randomized clinical trials, the question of whether to recommend antibiotic prophylaxis or not in certain patient populations remains unanswered and remains largely based on expert consensus opinion.

Keywords: Antibiotic prophylaxis; Infective endocarditis.*4

Abstract

Background: In 2007, the American Heart Association published updated evidence-based guidelines on the recommended use of antibiotic prophylaxis to prevent viridans group streptococcal (VGS) infective endocarditis (IE) in cardiac patients undergoing invasive procedures. The 2007 guidelines significantly scaled back the underlying conditions for which antibiotic prophylaxis was recommended, leaving only 4 categories thought to confer the highest risk of adverse outcome. The purpose of this update is to examine interval evidence of the acceptance and impact of the 2007 recommendations on VGS IE and, if needed, to make revisions based on this evidence.

Methods and results: A writing group was formed consisting of experts in prevention and treatment of infective endocarditis including members of the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics, in addition to the American Heart Association. MEDLINE database searches were done for English language articles on compliance with the recommendations in the 2007 guidelines and the frequency of and morbidity or mortality from VGS IE after publication of the 2007 guidelines. Overall, there was good general awareness of the 2007 guidelines but variable compliance with recommendations. There was no convincing evidence that VGS IE frequency, morbidity, or mortality has increased since 2007.

Conclusions: On the basis of a review of the available evidence, there are no recommended changes to the 2007 VGS IE prevention guidelines. We continue to recommend VGS IE prophylaxis only for categories of patients at highest risk for adverse outcome while emphasizing the critical role of good oral health and regular access to dental care for all. Randomized controlled studies to determine whether antibiotic prophylaxis is effective against VGS IE are needed to further refine recommendations.

Keywords: AHA Scientific Statements; antibiotic prophylaxis; dental care; endocarditis; oral health; viridans streptococci.*5

*1Infective endocarditis: A contemporary update

Ronak Rajani et al. Clin Med (Lond). 2020 Jan.

*2[Update on endocarditis 2024]

[Article in German]

Nils Petri et al. Inn Med (Heidelb). 2024 May.

*3Erratum in

Erratum zu: ESC-Leitlinien 2023 zum Management der Endokarditis.

de Waha S, et al. Herz. 2024. PMID: 

*4Infective Endocarditis Antibiotic Prophylaxis: Review of the Evidence and Guidelines

Mia M Pries-Heje et al. Curr Cardiol Rep. 2023 Dec.

*5 Adapted from: Prevention of Viridans Group Streptococcal Infective Endocarditis: A Scientific Statement From the American Heart Association

Walter R Wilson et al. J Am Dent Assoc. 2021 Nov.

Hipertiroidismo y arritmias cardiacas (bloqueo AV)

 Abstract

Subclinical hyperthyroidism is a difficult entity to diagnose because of silent clinical features and it may be easily underdiagnosed unless it is suspected and thyroid hormone levels are examined. Although atrioventricular (AV) conduction abnormalities such as complete heart block may occasionally be seen in hyperthyroidism, its association with subclinical hyperthyroidism has not been reported previously. We report on a 50-year-old female patient who did not have any systemic or cardiovascular disease or history of drug use that could affect AV conduction and presented with presyncope and complete heart block with narrow QRS complexes. Thyroid function tests showed subclinical hyperthyroidism and an electrophysiological study showed the supra-His level as the site of complete AV block. After initiation of antithyroid treatment (propylthiouracil), the patient's rhythm improved to second-degree AV block on the third day and returned to normal sinus rhythm on the fourth day.*1

Abstract

Background: Hypothyroidism is a reversible cause of atrioventricular (AV) block. Few reports have described reversible AV block caused by hyperthyroidism. However, it is unknown whether patients with AV block are expected to have a benign course after the initiation of appropriate therapy for thyroid dysfunction.

Methods: The study group consisted of patients with II or III degree AV block and bradyarrhythmia (≤40bpm) excluding patients with myocardial infarction, electrolyte abnormalities, digitalis toxicity, and vasovagal syncope. Thyroid dysfunction is diagnosed when thyroid stimulating hormone and thyroxine levels are not in defined normal ranges. AV block was determined by surface electrocardiogram (ECG). The cause and effect relation between AV block and thyroid dysfunction was evaluated.

Results: Of 668 patients, 29 (4.3%) had hypothyroidism (19 overt) and 21 (3.1%) had hyperthyroidism (8 overt). The most frequent ECG finding was complete AV block (27 of 50 patients). Ten patients had bradyarrhythmia and 13 had second-degree AV block. Euthyroid state was achieved in 10 hypothyroidic (34%) and in 7 hyperthyroidic patients (33%) with hormone replacement and antithyroid therapy, respectively, during the follow-up period (≤21 days). Thyroid dysfunction was found to be not related with AV block in 40 patients (80%). However, in 4 of 10 patients with AV block related to thyroid dysfunction the resolution of AV block occurred after the placement of pacemaker (>21 days). Overall, 44 of 50 (88%) patients with AV block in association with thyroid dysfunction were implanted with a permanent pacemaker. Of 6 patients who did not receive a pacemaker, 2 had complete AV block and 4 had bradyarrythmia.

Conclusion: AV block associated with thyroid dysfunction needs great attention regardless of type of the thyroid disease. Patients with II and/or III degree AV block in the setting of thyroid dysfunction almost always need permanent pacemaker insertion even after normalization of thyroid status. *2

Abstract

Hyperthyroidism often causes tachyarrhythmia. Reversible atrioventricular block caused by hyperthyroidism is rare occurrence. Presently described is a case of atrioventricular block due to hyperthyroidism and recovery after antithyroid treatment.

PubMed Disclaimer *3

Abstract

The authors report the case of a 26-year old male patient who had Graves' disease with a first degree atrioventricular block (AVB) and intermittent episodes of a second degree AVB of the Lucciani-Wenckebach type. These disorders of conduction had features characteristic of a nodal block and disappeared after treatment of the hyperthyroidism. The pathogenesis of atrioventricular conduction disorders in hyperthyroidism remains controverted. The authors put forward the following hypothesis: under the influence of thyroid hormones in excessive amounts, the autonomic nervous system would act by reciprocal excitation and exacerbate a patent or latent hypervagotonia which was pre-existent to the hyperthyroidism. This hypothesis needs to be tested by intracardiac electrophysiological studies with atrial stimulation.*4

Abstract

Complete heart block developed in a 29-year-old man with hyperthyroidism and acute febrile illness. The definite cause of acute febrile illness was unknown. The results of bacteriological and viral studies were negative. Endomyocardial biopsy revealed no evidence of carditis which is the common cause of heart block. All the abnormalities resolved completely after the fever subsided and the patient was treated with an antithyroid drug. Available information indicates that a high degree of heart block can sometimes occur in hyperthyroidism in either the presence or absence of additional factors which can independently impair atrioventricular conduction. This course of events which occurred in this patient suggest that complete heartblock may have been the direct manifestation of the hyperthyroid state, however, the acute febrile illness may have been an aggravating factor in the development of abnormal atrioventricular conduction.*5

PubMed Disclaimer*5

*1 Supra-His complete atrioventricular block in a patient with subclinical hyperthyroidism]

[Article in Turkish]

Basri Amasyalı et al. Turk Kardiyol Dern Ars. 2011 Dec.

*2Atrioventricular block in patients with thyroid dysfunction: prognosis after treatment with hormone supplementation or antithyroid medication

Kazim Serhan Ozcan et al. J Cardiol. 2012 Oct.

*3 Reversible first-degree atrioventricular block due to hyperthyroidism]

*4Hyperthyroidism and atrioventricular block. Pathogenic hypothesis. Apropos of a case and review of the literature]

[Article in French]

F Toloune et al. Arch Mal Coeur Vaiss. 1988 Sep

*5Complete heart block complicating hyperthyroidism: a case report

S Sriussadaporn et al. J Med Assoc Thai. 1990 Jan.

Enfermedad del nódulo sinusal y tratamiento

 Abstract

Introduction and objectives: Since physiological pacing systems have become available, a debate has raged about the merits of atrial versus ventricular pacing in the sick sinus syndrome. The goal of this retrospective report was to study the long term incidence and the independent predictors for atrial fibrillation and stroke in 153 paced patients with sick sinus syndrome, adjusting for differences in baseline clinical variables with multivariate analysis.

Method and results: From 1980 to 1994, we implanted 32 dualchamber, 33 atrial, and 88 ventricular pacemakers to treat patients with sick sinus syndrome. After a maximum follow-up of 177 months (median 30 months for paroxismal atrial fibrillation, 45 months for chronic atrial fibrillation and 43,5 months for stroke) the actuarial incidence of paroximal atrial fibrillation was 7.8% at 1 year, 29% at 5 years and 42% at 10 years. The actuarial incidence of chronic atrial fibrillation was 1.3% at 1 year, 9.8% at 5 years and 22% at 10 years. Independent predictors for paroxismal AF from Cox's model was history of atrial tachyarrhythmias (p < 0.0001), chronic obstructive pulmonary disease (p = 0,006) and age (> 70 years-old) (p = 0.035). Only a history of atrial tachyarrhythmias before pacemaker implant was an independent predictor for chronic atrial fibrillation (p < 0.0001). The odd ratio for paroxismal atrial fibrillation in patients with previous atrial tachyarrhythmias and chronic atrial fibrillation were 6 (2.8-12) and 4 (1.6-9.7) (95% confiance limits). Actuarial incidence of stroke was 3% at 1 year, 10% at 5 years and 14% at 10 years. Independent predictors for stroke were history of peripheral vascular disease (p = 0.033) and hypertensive cardiomyopathy (p = 0.015). Development of paroxysmal and chronic atrial fibrillation during the follow-up were higher in patients with stroke (p < 0.001 and p < 0.05).

Conclusions: Development of atrial fibrillation and stroke in paced patients with sick sinus syndrome are strongly determined by clinical variables. Preimplant paroxysmal atrial tachyarrhythmias is the most important predictor for atrial fibrillation in the follow-up.*1

Abstract

Several studies reported that the annual incidence of stroke in patients with sick sinus syndrome ranges from 6 to 10% while the incidence of stroke in patients with atrial fibrillation is about 2-4% and about 0.1% in the normal population. We evaluated the prevalence of cerebral ischemia and peripheral embolism and investigated the predictor factors in a population of 80 patients paced for sick sinus syndrome. The implanted pacemakers were 40 ventricular and 40 physiological stimulation mode was based on the physicians judgement. All patients had cerebral computed tomography scan at the time of implant and after 24 months. Statistical analysis included log-rank test and actuarial curve calculated with Mantel-Haenszel method. At the end of follow-up the end-point occurred in 15 patients: 2 patients had asymptomatic cerebral infarction, 2 had fatal stroke, 2 developed peripheral embolysm, 1 to the lower limb and 1 abdominal; in 4 patients a transient ischemic attack occurred, in 2 a minor stroke and in 3 a non invalidant stroke. No statistically significant difference was found among the subgroups; with different pacing modality. In conclusion, multivariate analysis underlines the role of age > 65 years, history of cerebral ischemia, low atrial ejection force and spontaneous echo contrast in the development of embolic episodes.*2

Abstract

Sinus node disease (SND), a common indication to implant a pacemaker, is frequently associated with atrial fibrillation (AF), either at implantation (paroxysmal AF) or during follow-up, which often evolves to persistent or permanent AF. Pacemakers with an atrial lead allow continuous monitoring of the atrial rhythm and enable detection of the burden of AF. Asymptomatic atrial tachyarrhythmias, being associated with increased risk of stroke, have important prognostic implications, and their detection could guide decision-making about antithrombotic prophylaxis. Pacing mode and pacing algorithms can influence the occurrence of AF and atrial tachyarrhythmias. In DDD/DDDR pacing mode, reduction of unnecessary right ventricular pacing positively affects the occurrence and evolution of AF, but patients with a history of atrial tachyarrhythmias maintain an increased risk of arrhythmic events. In the MINERVA study, the use of algorithms that act in the atrium for preventive pacing and atrial antitachycardia pacing while minimizing right ventricular pacing was beneficial in patients with SND and previous atrial tachyarrhythmias, and was associated with a significant reduction in evolution to permanent AF. New information available on therapies delivered at the atrial level by implanted devices suggests clinical advantages that could improve current guidelines for the management of AF and atrial tachyarrhythmias.*3

Abstract

Purpose of review: The goal of this paper is to review present knowledge regarding preventive and antitachycardia pacing algorithms, aimed to reduce atrial fibrillation (AF) burden in patients when pacing is indicated.

Recent findings: Reactive antitachycardia pacing (ATP), the new generation of ATP, is significantly associated with a reduced risk of AF. In patients with indication for pacing and history of AF, pacemakers endowed with atrial preventive pacing and atrial ATP combined with managed ventricular pacing proved superior to standard dual-chamber pacing. Managed ventricular pacing is an algorithm that minimizes unnecessary right ventricular pacing. Progression to persistent AF is prevented by ventricular pacing minimization in patients with normal PR interval. The synergistic effect of pacemakers that combine atrial preventive pacing with reactive ATP and with algorithms that minimize ventricular pacing can reduce AF incidence and decrease the combined endpoint of permanent AF, hospital admissions, and mortality.

Keywords: Antitachycardia pacing; Atrial fibrillation; Atrial pacing therapies; Pacing minimization algorithms. *4

Abstract

Background: Atrial fibrillation (AF) is a frequent comorbidity in patients with pacemaker and is a recognized cause of mortality, morbidity, and quality-of-life impairment. The international MINimizE Right Ventricular pacing to prevent Atrial fibrillation and heart failure trial established that atrial preventive pacing and atrial antitachycardia pacing (DDDRP) in combination with managed ventricular pacing (MVP) reduce permanent AF occurrence in comparison with standard dual-chamber pacing (DDDR).

Objective: We aimed to determine the role of new-generation atrial antitachycardia pacing (Reactive ATP) in preventing AF disease progression.

Methods: Patients with dual-chamber pacemaker and with previous atrial tachyarrhythmias were randomly assigned to DDDR (n = 385 (33%)), MVP (n = 398 (34%)), or DDDRP+MVP (n = 383 (33%)) group. The incidence of permanent AF, as defined by the study investigator, or persistent AF, defined as ≥7 consecutive days with AF, was estimated using the Kaplan-Meier method, while its association with patients' characteristics was evaluated via multivariable Cox regression.

Results: At 2 years, the incidence of permanent or persistent AF was 26% (95% confidence interval [CI] 22%-31%) in the DDDR group, 25% (95% CI 21%-30%) in the MVP group, and 15% (95% CI 12%-20%) in the DDDRP+MVP group (P < .001 vs. DDDR; P = .002 vs. MVP). Generalized estimating equation-adjusted Reactive ATP efficacy was 44.4% (95% CI 41.3%-47.6%). Multivariate modeling identified high Reactive ATP efficacy (>44.4%) as a significant predictor of reduced permanent or persistent AF risk (hazard ratio 0.32; 95% CI 0.13-0.781; P = .012) and episodes' characteristics, such as long atrial arrhythmia cycle length, regularity, and the number of rhythm transitions, as predictors of high ATP efficacy.

Conclusion: In patients with bradycardia, DDDRP+MVP delays AF disease progression, with Reactive ATP efficacy being an independent predictor of permanent or persistent AF reduction.

Keywords: Antitachycardia pacing; Atrial fibrillation; Pacemaker; Reactive ATP. *5

*1Auricular fibrillation and stroke in patients with sick sinus syndromeusing permanent pacemakers]

[Article in Spanish]

R Sanjuán Máñez et al. Rev Esp Cardiol. 1996 Jul.

*2Stroke in pacemaker users for sinus disease. Relevance of atrial function and clinical characteristics].

*3Management of atrial fibrillation in bradyarrhythmias

Giuseppe Boriani et al. Nat Rev Cardiol. 2015 Jun.

*4 Programming Pacemakers to Reduce and Terminate Atrial Fibrillation

Margarida Pujol-López et al. Curr Cardiol Rep. 2019.

*5New-generation atrial antitachycardia pacing (Reactive ATP) is associated with reduced risk of persistent or permanent atrial fibrillation in patients with bradycardia: Results from the MINERVA randomized multicenter international trial

Luigi Padeletti et al. Heart Rhythm. 2015 Aug.