Findings on Doppler echocardiography in asymptomatic intravenous heroin users

Preclinical mitigation of 5-HT2B agonism-related cardiac valvulopathy revisited

Cardiac valvulopathy (Cardiac Valve Disease; CVD) associated with off-target activation of the 5-hydroxytryptamine (5-HT) 2B receptor has been well recognized, but is still poorly predicted during drug development. The regulatory guidance proposes the use of 5-HT2B binding data (i.e., Ki values) and free maximum therapeutic exposure (Cmax) to calculate safety margins as a threshold of detection (>10) for eliminating the risk of drug-induced cardiac valvulopathy. In this paper, we provide additional recommendations for preclinical prediction of CVD risk based on clinical pharmacodynamic and pharmacokinetic data obtained from drugs with or without 5-HT2B receptor activation. Our investigations showed that 5-HT2B agonist affinity of molecules tested in an in vitro 5-HT2B cell-based functional assay, placed in perspective to their sustained plasma exposure (AUCs) and not to their peak plasma exposure, Cmax (i.e., maximum therapeutic exposure) provide a solid basis for interpreting 5-HT2B data, for calculating safety margins and then, accurately differentiate drugs associated with a clinical risk of CVD from those which are not (despite having some agonist 5-HT2B activity). In addition, we discuss the risk of multi-organ fibrosis linked to 5-HT2B receptor activation, often underestimated, however well reported in FAERS for 5-HT2B agonists. We believe that our recommendations have the potential to mitigate the risk for the clinical development of CVD and fibrosis.

Ventricular Septal Defect and Right-Sided Infective Endocarditis

Right-sided infective endocarditis (IE), which represents a small but not negligible percentage of IE cases, can be observed in patients with congenital heart diseases. We discuss the case of a young woman with unrepaired perimembranous ventricular septal defect and repeated episodes of right ventricle and tricuspid valve IE with septic embolism.

Effect of Heroin on Electrocardiographic Parameters

Fundamento

Atualmente, o vício em heroína é um problema de saúde preocupante, e as informações sobre os efeitos eletrocardiográficos da heroína são limitadas.

Objetivos

O objetivo do presente estudo é investigar os efeitos da dependência de heroína em parâmetros eletrocardiográficos.

Métodos

Um total de 136 indivíduos, incluindo 66 indivíduos que fumam heroína como grupo de estudo e 70 indivíduos saudáveis sem dependência de drogas como grupo de controle, foram incluídos no estudo. Indivíduos que injetam heroína foram excluídos. A avaliação eletrocardiográfica (ECG) dos usuários de heroína foi realizada e comparada com as do grupo controle. Além disso, os ECGs pré e pós-tratamento do grupo usuário de heroína foram comparados. Um valor de p<0,05 foi aceito como estatisticamente significativo.

Resultados

A frequência cardíaca (77,2±12,8 versus 71,4±11,2; p=0,02) foi maior no grupo usuário de heroína em comparação com o grupo controle. Os intervalos QT (341,50±25,80 versus 379,11±45,23; p=0,01), QTc (385,12±29,11 versus 411,3±51,70; p<0,01) e o intervalo do pico ao fim da onda T (Tpe) (65,41±10,82 versus 73,3±10,13; p<0,01) foram significativamente menores no grupo usuário de heroína. Nenhuma diferença foi observada entre os grupos com respeito às razões Tpe/QT e Tpe/QTc. Na análise de subgrupo do grupo usuário de heroína, os intervalos QT (356,81±37,49 versus 381,18±40,03; p<0,01) e QTc (382,06±26,41 versus 396,06±29,80; p<0,01) foram significativamente mais curtos no período pré-tratamento.

Conclusão

O vício em heroína afeta significativamente os intervalos de tempo QT, QTc e Tpe. Os efeitos de arritmia desses parâmetros já são conhecidos. Os parâmetros eletrocardiográficos desses indivíduos merecem mais atenção. (Arq Bras Cardiol. 2020; 115(6):1135-1141)

Right-Sided Infective Endocarditis 2020: Challenges and Updates in Diagnosis and Treatment

Compared with the extensive data on left-sided infective endocarditis (IE), there is much less published information on the features and management of right-sided IE. Right-sided IE accounts for 5% to 10% of all IE cases, and compared with left-sided IE, it is more often associated with intravenous drug use, intracardiac devices, and central venous catheters, all of which has become more prevalent over the past 20 years. In this manuscript on right-sided IE we provide an up-to-date overview on the epidemiology, etiology, microbiology, potential locations of infection in the right heart, diagnosis, imaging, common complications, management, and prognosis. We present updated information on the treatment of pacemaker and device infections, infected fibrin sheaths that appear to be an easily missed source of infection after central line as well as pacemaker removal. We review current data on the AngioVac percutaneous aspiration device, which can obviate the need for surgery in patients with infected pacemaker leads and fibrin sheaths. We also focused on advanced diagnostic modalities, such as positron emission tomography/computed tomography. All of these are supported by specific case examples with detailed echocardiographic imaging from our experience.

Medical complications of opioid use disorder in pregnancy

Women with opioid use disorder are at increased risk of other medical complications of pregnancy. Providing care for such complex patients requires the ability to 1) acknowledge addiction as a chronic disease, 2) incorporate the altered physiology of pregnancy, and 3) devise a treatment plan that can effectively manage acute conditions. A basic tenet of care is rooted in experience, rather than evidence, but includes stabilization of opiate use disorder (OUD) as a primary goal of management of other medical complications of pregnancy. Proceeding with treatment for other medical conditions will be suboptimal without stabilization of the underlying chronic disease process. This chapter outlines some associated medical complications of OUD both in general and some of which are unique to pregnancy: infectious diseases, soft tissue infections, endocarditis, cholestasis of pregnancy, and overdose.

Bilateral Pneumothoraces: A Rare Complication of Septic Pulmonary Emboli in Intravenous Drug Abusers

Patient: Male, 39

Final Diagnosis: Infective endocarditis

Symptoms: Cough

Medication: —

Clinical Procedure: None

Specialty: Critical Care Medicine

In-hospital infective endocarditis following transcatheter aortic valve replacement: a cross-sectional study of the National Inpatient Sample database in the USA

BACKGROUND

While the utilization of transcatheter aortic valve replacement (TAVR) for patients with severe aortic stenosis has been increasing, in-hospital infective endocarditis (IE) following TAVR has not been well described.

AIM

To identify in-hospital IE following TAVR.

METHODS

All patients who underwent TAVR between 2012 and 2014 were identified using the National Inpatient Sample database. Multi-variate logistic regression was performed to identify the predictors of in-hospital IE after TAVR.

FINDINGS

Of the 41,025 patients who received TAVR, 120 patients (0.3%) developed in-hospital IE. Viridans group streptococci (20.8%) was the most frequent causative organism for in-hospital IE, followed by Staphylococcus aureus (16.7%) and enterococci (8.3%). Patients who developed in-hospital IE after TAVR had significantly higher rates of death (20.8% vs 4.1%, P<0.001), septic shock (16.7% vs 0.8%, P<0.001), cardiogenic shock (12.5% vs 3.4%, P=0.02), acute kidney injury requiring haemodialysis (16.7% vs 1.6%, P<0.001), bleeding requiring transfusion (29.2% vs 11.3%, P=0.01), myocardial infarction (12.5% vs 2.1%, P<0.001) and permanent pacemaker removal (4.2% vs 0.05%, P<0.001) compared with patients without IE. Independent predictors of in-hospital IE after TAVR include younger age [odds ratio (OR) 0.92, 95% confidence interval (CI) 0.89-0.95], drug abuse (OR 48.9, 95% CI 6.9-347.3) and human immunodeficiency virus (HIV) infection (OR 7.8, 95% CI 1.4-44.4).

CONCLUSION

IE occurred in 0.3% of patients after TAVR during the same hospitalization, resulting in higher rates of adverse outcomes including mortality. Patients with younger age, a history of drug abuse or HIV infection are at greater risk of in-hospital IE following TAVR, and would benefit from vigilant preventive measures perioperatively.

Right-Sided Infective Endocarditis and Pulmonary Infiltrates: An Update

Sixty years after its initial description, right-sided infective endocarditis (RSIE) still poses a challenge to all medical practitioners. Epidemiological data reveal a rising incidence attributable to the global surge in the number of intravenous drug users and the increased use of central vascular catheters and implantable cardiac devices. RSIE differs from left-sided infective endocarditis in more than just the location of the involved cardiac valve. They have different clinical presentations, diagnostic findings, and prognoses; hence, they require different management strategies. Cardiac murmurs and systemic emboli are usually absent in RSIE, whereas pulmonary embolism and its related complications dominate the clinical picture. Diagnostic delay of RSIE is secondary to the similarity in its initial presentation to other entities. Complications may ensue as a result of this delay. Diagnosis can be initially confirmed by using transthoracic echocardiography, except in patients with implanted cardioverter defibrillator, where a transesophageal echocardiogram is necessary. Various factors may increase mortality and morbidity in RSIE such as tricuspid valve vegetation size, fungal etiology, and low CD4 cell count in HIV patients. Oxacillin and vancomycin had been the traditionally used agents for the treatment of methicillin-susceptible and methicillin-resistant Staphylococcus aureus, respectively. More recently, daptomycin has shown promising results, which has led to its Food and Drug Administration (FDA) approval for the treatment of S. aureus bacteremia and associated RSIE. The aim of this article is to provide a comprehensive update on RSIE including epidemiology, pathogenesis, microbiology, diagnosis, management, and prognosis.

Coxiella burnetii Infection in a Community Operating a Large-Scale Cow and Goat Dairy, Missouri, 2013

Coxiella burnetii is a zoonotic pathogen that causes Q fever in humans and is transmitted primarily from infected goats, sheep, or cows. Q fever typically presents as an acute febrile illness; however, individuals with certain predisposing conditions, including cardiac valvulopathy, are at risk for chronic Q fever, a serious manifestation that may present as endocarditis. In response to a cluster of Q fever cases detected by public health surveillance, we evaluated C. burnetii infection in a community that operates a large-scale cow and goat dairy. A case was defined as an individual linked to the community with a C. burnetii phase II IgG titer ≥ 128. Of 135 participants, 47 (35%) cases were identified. Contact with or close proximity to cows, goats, and their excreta was associated with being a case (relative risk 2.7, 95% confidence interval 1.3-5.3). Cases were also identified among individuals without cow or goat contact and could be related to windborne spread or tracking of C. burnetii on fomites within the community. A history of injection drug use was reported by 26/130 (20%) participants; follow-up for the presence of valvulopathy and monitoring for development of chronic Q fever may be especially important among this population.

A chest wall pulsating mass

A 34-year-old HIV-positive man with intravenous drug addiction presented with a 2-week history of fever and a pulsatile presternal mass; 2 weeks prior he had suffered a traumatic sternal fracture. The CT scan showed a bulky abscess with presternal and retrosternal extension that contacted the heart (which explained its pulsatile effect) and pulmonary necrotising lesions. Drainage of the thoracic wall abscess was performed, and antibiotics (flucloxacillin plus gentamicin) were started on the presumption of staphylococcal bacteraemia given the patient's intravenous drug habit. Blood cultures and culture of the aspirated pus confirmed growth of methicillin-sensitive Staphylococcus aureus; transoesophageal echocardiography showed endocarditis of the tricuspid valve. We therefore assumed pulmonary septic embolisation from right-sided endocarditis and acute sternal osteomyelitis, and the patient was treated for 6 weeks with clinical resolution.

Echocardiographic findings suggestive of infective endocarditis in asymptomatic Danish injection drug users attending urban injection facilities

Injection drug users (IDUs) account for a considerable number of the hospitalizations for infective endocarditis (IE), but the prevalence of diagnosed and unrecognized IE in IDUs is unknown. The aim of the present study was to assess the prevalence of valvular abnormalities suggestive of IE in IDUs attending a supervised injection facility. We performed transthoracic echocardiographic examinations on-site in the injection facilities. A total of 206 IDUs (mean age 43 ± 9 years, 23% women) with a median injection drug abuse of 18 years (interquartile range 10 to 26) were included. Fourteen IDUs (14 of 206, 7%, 95% confidence interval [CI] 4% to 11%) had a previous history of IE. IDUs with a history of IE were significantly older than IDUs without a history of IE (48 ± 8 vs 42 ± 9 years, respectively, p = 0.03) and had a longer duration of injection drug use (27 [18 to 36] vs 17 years [10 to 25], p = 0.008). In the subgroup of IDUs with a history of IE, 4 subjects (4 of 14, 29%, 95% CI 11% to 55%) had persistent or relapse vegetations. Of the remaining 10 IDUs with a history of IE, 5 (5 of 10, 50%, 95% CI 24% to 76%) had moderate-to-severe regurgitation. In the subgroup of IDUs without a history of IE, vegetations were seen in 9 subjects (9 of 192, 5%, 95% CI 2% to 9%). This group of IDUs with possibly unrecognized IE was older than IDUs without vegetations (48 ± 12 vs 42 ± 9, respectively, p = 0.04). Among the IDUs without a history of IE who did not have vegetations, 30 IDUs (30 of 183, 16%, 95% CI 11% to 22%) had moderate-to-severe regurgitation with or without concomitant thickening of leaflets. Thus, in IDUs without a history of IE, some extent of valvular abnormalities was seen in 20% (39 of 192, 95% CI 15% to 27%) of subjects. None of the IDUs with valvular vegetations had current symptoms consistent with active IE. In conclusion, valvular abnormalities assessed by echocardiography were prevalent in asymptomatic IDUs without a medical history of IE, and vegetations were seen in 5% of subjects.

Incidence of, risk factors for, clinical presentation, and 1-year outcomes of infective endocarditis in an urban HIV cohort

BACKGROUND

Previous studies described infective endocarditis (IE) in the era before highly active antiretroviral therapy (HAART); however, IE has not been well studied in the current HAART era. We evaluated the incidence of, risk factors for, clinical presentation, and 1-year outcomes of IE in HIV-infected patients.

METHODS

We evaluated all cases of IE diagnosed between 1990 and 2002 in patients followed at the Johns Hopkins Hospital outpatient HIV clinic. To identify factors associated with IE in the current era of HAART, a nested case-control analysis was employed for all initial episodes of IE occurring between 1996 and 2002. Logistic regression analyses were used to assess risk factors for IE and factors associated with 1-year mortality.

RESULTS

IE incidence decreased from 20.5 to 6.6 per 1000 person-years (PY) between 1990 and 1995 and 1996 and 2002. The majority of IE cases were male (66%), African American (90%), and injection drug users (IDUs) (85%). In multivariate regression, an increased risk of IE occurred in IDUs (AOR, 8.71), those with CD4 counts <50 cells/mm, and those with HIV-1 RNA >100,000 copies/mL (AOR, 3.88). Common presenting symptoms included fever (62%), chills (31%), and shortness of breath (26%). The most common etiologic organism was Staphylococcus aureus (69%; of these 11 [28%] were methicillin resistant). Within 1 year, 16% had IE recurrence, and 52% died. Age over 40 years was associated with increased mortality.

CONCLUSIONS

IE rates have decreased in the current HAART era. IDUs and those with advanced immunosuppression are more likely to develop IE. In addition, there is significant morbidity and 1-year mortality in HIV-infected patients with IE, indicating the need for more aggressive follow-up, especially in those over 40 years of age. Future studies investigating the utility of IE prophylaxis in HIV patients with a history of IE may be warranted.

Prevalence of cardiac valve abnormalities in afebrile injection drug users

OBJECTIVES

To determine the prevalence of occult valvular pathology in afebrile injection drug users (IDUs) compared with an afebrile, non-IDU population. To characterize the type of valvular pathology present in light of current recommendations regarding periprocedural antibiotic prophylaxis against endocarditis.

METHODS

This was a comparative, cross-sectional study involving a convenience sample of 98 patients with a history of injection drug use, and 99 non-IDU patients presenting to a large urban ED. Patients were excluded if they had one or more of the following: a history of cardiac valve abnormality, a history of endocarditis, fever on presentation, or a cardiac murmur. Data were collected that included demographics, medical history, and details of injection drug use. Transthoracic echocardiography (echo) was performed on each subject in the ED, and read in a blinded fashion by a single board-certified cardiologist.

RESULTS

Among 98 IDUs and 99 non-IDUs, 12% of the IDUs had aortic valve thickening, compared with 5.1% of the non-IDUs (99% CI for difference of 7.8% = -3.0% to 18.6%). Forty-four percent of the IDUs had mitral valve thickening, compared with 25% of the non-IDUs (99% CI for difference of 18.3% = 0.9% to 35.7%). Eleven percent of the IDUs vs 1% of the non-IDUs had tricuspid valve thickening (99% CI for difference of 10.4% = 1.6% to 19.2%). No patient had pulmonic valve thickening. Six percent of the IDUs vs 0% of the non-IDUs had mitral annulus thickening (99% CI for difference of 6.3% = -0.1% to 12.8%). Twelve percent of the IDUs vs 3% of the non-IDUs had mitral chordae thickening (99% CI for difference of 9.5% = -0.4% to 19.4%). Tricuspid chordae thickening was recorded in 2% of the IDUs vs 0% of the non-IDUs (99% CI for difference of 2.1% = -1.7% to 6.0%). Most important, the prevalence of valvular regurgitation was small, and evenly distributed in the two groups. No valvular vegetations were seen.

CONCLUSION

Both non-IDUs and IDUs have occult valvular pathology. There is an increased prevalence in IDUs of tricuspid and mitral valve thickening. The prevalence of valvular regurgitation, a reported indication for periprocedural antibiotic prophylaxis, was small and the affected valves were not statistically different between the two groups. These findings question the selected routine use of antibiotic prophylaxis in IDU patients undergoing invasive procedures.