Endocarditis in the setting of IDU: multidisciplinary management.

PURPOSE OF REVIEW: The purpose of this article is to provide a brief overview of the medical and surgical management of infective endocarditis secondary to IDU, with a focus on the underlying substance use disorder. RECENT FINDINGS: Patients with infective endocarditis secondary to IDU are often young with unique comorbidities including mental illness, chronic hepatitis C, HIV infection, which are often compounded by limited social and familial supports. The focus of management has been treatment of endocarditis using IV antibiotics alongside surgery. Surgical outcomes compare favorably with those of infective endocarditis in the general population but long-term outcomes of IDUs are significantly worse. This is primarily due to the high rate of recidivism of drug use and the risk of prosthetic valve infective endocarditis. Contemporary management of addiction utilizes an integrative approach, combining both pharmacologic and nonpharmacologic strategies while remaining patient-centered. Given the complexity of care required, we advocate for a multidisciplinary team-based approach including psychiatry, infectious disease, cardiology, cardiac surgery and social services. SUMMARY: Infective endocarditis secondary to IDU remains a medical and surgical challenge with dismal outcomes. Here we offer practical suggestions on the multidisciplinary management of this challenging and high-risk patient cohort.

Low-dose daily folic acid (400 µg) supplementation does not affect regulation of folate transporters found present throughout the terminal ileum and colon of humans: a randomized clinical trial.

BACKGROUND: Folic acid supplementation during the periconceptional period reduces the risk of neural tube defects in infants, but concern over chronic folic acid exposure remains. An improved understanding of folate absorption may clarify potential risks. Folate transporters have been characterized in the small intestine, but less so in the colon of healthy, free-living humans. The impact of folic acid fortification or supplementation on regulation of these transporters along the intestinal tract is unknown. OBJECTIVE: The objective was to characterize expression of folate transporters/receptor (FT/R) and folate hydrolase, glutamate carboxypeptidase II (GCPII), from the terminal ileum and throughout the colon of adults and assess the impact of supplemental folic acid. METHODS: In this 16-wk open-labeled randomized clinical trial, adults consumed a low folic acid-containing diet, a folate-free multivitamin, and either a 400 µg folic acid supplement or no folic acid supplement. Dietary intakes and blood were assessed at baseline, 8 wk, and 16 wk (time of colonoscopy). Messenger RNA (mRNA) expression and protein expression of FT/R and GCPII were assessed in the terminal ileum, cecum, and ascending and descending colon. RESULTS: Among 24 randomly assigned subjects, no differences in dietary folate intake or blood folate were observed at baseline. Mean ± SD red blood cell folate at 16 wk was 1765 ± 426 and 911 ± 242 nmol/L in the 400 and 0 µg folic acid group, respectively (P < 0.0001). Reduced folate carrier, proton-coupled folate transporter, and folate-receptor alpha expression were detected in the terminal ileum and colon, as were efflux transporters of breast cancer resistance protein and multidrug resistance protein-3. Other than a higher mRNA expression of FR-alpha and GCPII in the 400 µg supplement group in the ascending colon, no treatment differences were observed (P < 0.02). CONCLUSIONS: Folate transporters are present throughout the terminal ileum and colon; there is little evidence that a low dose of folic acid supplementation affects colonic absorption. This trial was registered at clinicaltrials.gov as NCT03421483.

Injection Drug Use Endocarditis: An Inner-City Hospital Experience.

BACKGROUND: There has been a rise in the incidence of injection drug use and associated infective endocarditis. METHODS: The clinical outcomes of 39 patients admitted with injection drug use-associated infective endocarditis were collected with a mean follow-up of 14 months. The outcomes were compared for patients treated medically with those undergoing surgical intervention. Re sults: The mean age was 39 ± 11 years; 54% were female. Thirty-two patients (82%) had native and 7 (18%) prosthetic infective endocarditis. The tricuspid valve was affected in 17 patients (43%), the mitral in 10 (26%), the aortic in 4 (10%), and multiple valves in 8 (20%). Sixteen (41%) patients underwent surgery, and 23 (59%) were treated with medical therapy. The indications for surgery included heart failure, systemic emboli, recurrent infection, and vegetation size ≥10 mm. Patients undergoing surgery had a higher rate of paravalvular abscess (25% vs 0%, P = 0.02), valve perforation (37% vs 11%, P = 0.04), and mitral valve involvement (44% vs 13%, P = 0.06), whereas medically treated patients had higher tricuspid valve involvement (61% vs 19%, P = 0.02). During follow-up, 26% of medical and 31% of surgical cohort patients died (P = 0.7). Mortality was highest (54%) among those who continued medical management despite an indication for surgery. Univariate predictors of mortality were age (odds ratio [OR] 1.09, 95% confidence interval [CI]: 1.01-1.17; P = 0.02), heart failure (OR 6.9; 95% CI: 1.24-37.49; P = 0.02), septicemia (OR 4.40; 95% CI:0.99-19.54; P = 0.05), and shock (OR 10.8; 95% CI: 1.68-69.92; P = 0.01). CONCLUSIONS: Despite contemporary therapy, patients with injection drug use-associated infective endocarditis remain at high risk of complications and poor clinical outcomes. These findings highlight the need for developing new care pathways and a team approach for effective management.

INTRODUCTION: Il y a eu une augmentation de l'incidence de l'endocardite infectieuse associée à l'usage de drogues par injection. MÉTHODES: Nous avons recueilli au cours d'un suivi moyen de 14 mois les résultats cliniques de 39 patients admis en raison d'une endocardite infectieuse associée à l'usage de drogues par injection. Les résultats ont été comparés pour les patients traités médicalement avec ceux subissant une intervention chirurgicale. RÉSULTATS: L'âge moyen était de 39 ± 11 ans; 54 % étaient des femmes. Trente-deux patients (82 %) avaient une endocardite infectieuse sur valve native et 7 (18 %), une endocardite infectieuse sur prothèse valvulaire. La valve tricuspide était touchée chez 17 patients (43 %), la valve mitrale, chez 10 patients (26 %), la valve aortique, chez 4 patients (10 %), et plusieurs valves, chez 8 patients (20 %). Seize (41 %) patients ont subi une intervention chirurgicale, et 23 (59 %) ont reçu un traitement médical. Les indications d'intervention chirurgicale étaient les suivantes : l'insuffisance cardiaque, les embolies systémiques, l'infection récurrente et la taille de la végétation ≥ 10 mm. Les patients qui avaient subi une intervention chirurgicale ont plus fréquemment eu des abcès paravalvulaires (25 % vs 0 %, P = 0,02), des perforations de valves (37 % vs 11 %, P = 0,04) et des atteintes de la valve mitrale (44 % vs 13 %, P = 0,06), tandis que les patients qui avaient reçu un traitement médical ont plus fréquemment eu des atteintes de la valve tricuspide (61 % vs 19 %, P = 0,02). Durant le suivi, 26 % des patients de la cohorte du traitement médical et 31 % des patients de la cohorte de l'intervention chirurgicale sont morts (P = 0,7). La mortalité était plus élevée (54 %) chez les patients qui poursuivaient la prise en charge médicale malgré l'indication chirurgicale. Les prédicteurs univariés de la mortalité étaient l'âge (rapport de cotes [RC] 1,09, intervalle de confiance [IC] à 95 % : 1,01-1,17; P = 0,02), l'insuffisance cardiaque (RC 6,9; IC à 95 % : 1,24-37,49; P = 0,02), la septicémie (RC 4,40; IC à 95 % : 0,99-19,54; P = 0,05) et le choc (RC 10,8; IC à 95 % : 1,68-69,92; P = 0,01). CONCLUSIONS: En dépit de l'approche thérapeutique contemporaine, les patients atteints d'une endocardite infectieuse associée à l'usage de drogues par injection restent exposés à un risque élevé de complications et de mauvais résultats cliniques. Ces résultats illustrent la nécessité d'élaborer de nouveaux cheminements cliniques et une approche du travail en équipe pour assurer une prise en charge efficace.

Short Duration vs Standard Duration of Dual-Antiplatelet Therapy After Percutaneous Coronary Intervention With Second-Generation Drug-Eluting Stents - A Systematic Review, Meta-Analysis, and Meta-Regression Analysis of Randomized Controlled Trials.

BACKGROUND: Current guidelines recommend 12 months of dual-antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation. Whether the duration of DAPT can be safely shortened with use of second-generation DESs is unclear. METHODS: We conducted a meta-analysis of randomized controlled trials comparing short duration (SD) (3-6 months) with standard longer duration (LD) (≥12 months) DAPT in patients treated with primarily second-generation DES implantation. Meta-regression was performed to explore the relationship between acute coronary syndrome (ACS) and the effect of DAPT duration. RESULTS: Six studies were included, with 12,752/13,928 (91.5%) patients receiving second-generation DESs. A total of 5367 patients (39%) had PCI in the setting of ACS. There was no difference in all-cause mortality (1.1% vs 1.2%; odds ratio [OR], 0.86; 95% confidence interval [CI], 0.63-1.18; P=.36) or cardiac mortality (0.9% vs 1.0%; OR, 0.92; 95% CI, 0.61-1.39; P=.69) with SD-DAPT vs LD-DAPT, respectively. Definite/probable stent thrombosis (0.5% vs 0.3%; OR, 1.33; 95% CI, 0.75-2.34; P=.51), myocardial infarction (1.5% vs 1.3%; OR, 1.17; 95% CI, 0.88-1.56; P=.29), and stroke (0.4% vs 0.4%; OR, 1.04; 95% CI, 0.60-1.81; P=.88) were similar between the groups. Compared with LD-DAPT, SD-DAPT was associated with lower clinically significant bleeding (0.9% vs 1.4%; OR, 0.64; 95% CI, 0.46-0.89; P=.01). Meta-regression analysis showed no significant association between the proportion of ACS patients in trials and duration of DAPT for the outcomes of mortality (P=.95), myocardial infarction (P=.98), or stent thrombosis (P=.89). CONCLUSION: In low-risk patients treated with contemporary second-generation DES implantation, SD-DAPT has similar rates of mortality, myocardial infarction, and stent thrombosis, with lower rates of bleeding compared with LD-DAPT.