Mary Ann McLaughlin, MD, MPH
Medical Director, Cardiac Health Program
Director, Women's Cardiac Assessment and Risk Evaluation Program
Mount Sinai Health System
Endocarditis: Are You at Risk for this 'Silent Killer'?
Endocarditis is an uncommon but potentially deadly disease of the heart. Sometimes deemed a "silent killer," its early symptoms can be relatively mild, causing some people to delay seeking care. But not getting prompt treatment can lead to devastating consequences.
What Is Endocarditis?
Endocarditis is an infection of the heart. It usually affects the heart valves, but can also involve the lining of the heart. If detected in time, it can be cured with antibiotics, but left untreated, it can damage the heart and other organs, and lead to stroke or even death.
What Causes Endocarditis?
We are constantly exposed to bacteria on our skin and in our mouth. If these bacteria enter the bloodstream, such as through a gum injury during a dental procedure or a puncture wound to the skin, most people with a healthy immune system will clear them. However, in those with certain heart abnormalities, such as an abnormal valve or hole in the heart, these bacteria can glom onto any irregular surface of the heart and multiply there. The blood can then carry the bacteria throughout the rest of the body.
A number of complications can arise, particularly in older patients with other health risks, like high blood pressure or smoking. For instance, a collection of bacteria can sit on the heart valves and destroy them. A stroke may result if a little piece of infection slides off and travels through the arteries into the brain. Because toxins are cleared from the body through the kidneys, an overwhelming infection can lead to kidney damage. It can also spread to other organs, causing a life-threatening condition called sepsis.
Who Is at Risk?
Anyone can develop endocarditis, but people at highest risk are those with:
•A congenital (present from birth) heart defect, such as a hole in the lining of the heart.
•A heart valve abnormality, such as mitral valve prolapse with severe leakage, or damage caused by rheumatic fever in childhood.
•An artificial heart valve or prosthetic material used in valve repair surgery.
•An intravenous (IV) catheter (thin tube) in the body, such as a kidney dialysis catheter.
•An implanted cardiac device with wires, such as a pacemaker or defibrillator.
•A transplanted heart with valve disease.
•A history of IV drug use. (Using dirty needles, sharing needles, and repeatedly accessing the skin intravenously can lead to endocarditis.)
•A previous episode of endocarditis.
Some people may be unaware of their risk, such as people who don't realize they had rheumatic fever as a child, or an older adult whose valve has become impaired over time.
What Symptoms Does It Cause?
Endocarditis can cause a variety of symptoms, which are often subtler than those of other serious infections. High fever and chills can occur, but some people may just feel tired and have joint and muscle pain and night sweats. Others may have a low-grade fever (99-101) lasting a couple of months. Symptoms may also include a cough, swelling in the legs, or shortness of breath. Some people may have a long episode of fever and chills, but forget about it when it goes away.
If you experience any of the above symptoms for more than seven days, see your doctor right away. And contact your doctor immediately if you have fever and chills along with any of the following signs that infection has spread throughout your body:
•Little nodules or red spots, called Osler's nodes, on the fingertips or under the fingernails;
•Splinter hemorrhages (thin dark lines) underneath the nail beds;
•Tiny purple spots on the skin or in the eyes;
•Blood in the urine.
Diagnosis is generally straightforward and based on various blood tests.
How Is It Treated?
Endocarditis is typically treated with an extended course of IV antibiotics, sometimes for as long as six weeks. Treatment starts in the hospital, where the patient's blood is tested repeatedly for bacteria. Patients stay in the hospital at least until the tests come back negative, meaning the infection has cleared from the bloodstream, which could take up to a week. Antibiotics are continued to ensure infection is also cleared from all the organs. Some people may go home with an IV catheter for continued treatment. At home, a visiting nurse comes once or twice a day to deliver antibiotics into the catheter, allowing patients to resume relatively normal lives throughout the rest of their treatment.
Tips for Preventing Infection and Complications
Practice good oral hygiene. Bacteria from unhealthy teeth or gums can enter the bloodstream even during normal cleaning. That's why it's important to keep your mouth clean and healthy with frequent brushing and flossing and regular dental checkups.
If you are at high risk, take antibiotics before dental procedures. The AHA guidelines for the prevention of endocarditis recommend antibiotic prophylaxis for dental procedures that go below the gum line or cause bleeding, such as deep cleaning or tooth extraction, for people at highest risk of complications from endocarditis: those with an artificial heart valve or prosthetic cardiac material, previous endocarditis, certain forms of congenital heart disease, or a transplanted heart with valve disease.
Take care when engaging in tattooing, piercing, or other practices that puncture the skin. Ensure they are done with sterile equipment on clean, uninfected skin. Note that the AHA recommends against body piercing for people at highest risk (see above).
Don't ignore seemingly mild symptoms. For instance, if you have been feeling unwell and your joints have ached longer than a week, or you've had a lingering low-grade fever, see your doctor and make sure he or she listens to your heart. If a new or changed murmur is heard, your doctor should suspect endocarditis and test your blood. If you do have endocarditis, the earlier you get started on antibiotics, the better your outcome will be.