Context and Definition

Endocarditis is defined as damage to the endocardium associated with thrombus formation. The endothelial lining of the heart covers all the internal structure of the heart including valvular surfaces. Endocarditis can be infective if colonised by bacteria or fungi or non-infective as in the case of Non Bacterial Thrombotic Endocarditis (NBTE).

Infective endocarditis

Infective endocarditis has a relatively low prevalence in developed countries, with incidence between 2 and 6 cases per 100,000 population per year. This incidence rises 30 to 200 fold in populations of intravenous drug users. Left untreated, it is a devastating disease that can prove fatal within a matter of weeks. Early detection and treatment is therefore paramount to improve clinical outcome.

Antibiotics

Availability and use of effective antibiotics has altered both the patient profile and disease progress. The usual patient now presents in the 6th decade of life, compared to the pre-antibiotic era when the typical patient was in their 30s. Moreover, use of antibiotics have altered the progress of the disease, and previous classifications of endocarditis into acute, sub-acute and chronic are no longer in widespread use.

Vegetation on valves

Vegetation on valves does not always represent an infective process. Loefflers endocarditis is a part of the hypereosinophilic syndrome, and responds well to treatment with steroids, hydroxyurea and anticoagulation. Non Bacterial Thrombotic Endocarditis (NBTE) is associated with endocardial damage due to trauma, or with hypercoagulable states or malignancies. Though it is usually sterile, it can be a site for subsequent infection.

Even though the emergency physician may not be involved in the long-term management of endocarditis, they do play a crucial role in diagnosis and initial management of endocarditis and its complications.