Infective endocarditis - A review of current therapy and future challenges.

Etiological, microbiological and epidemiological factors changed over time, but mortality rates remain high in infective endocarditis (IE). Healthcare-associated IE is nowadays responsible for a significant proportion of cases due to increasing numbers of cardiac devices. Cardiac implantable electronic devices, transcatheter aortic valve replacement, and percutaneous valve repair are meanwhile used, especially in old and sick patients. In suspected IE modified Duke criteria, integrating clinical results, imaging, and biomarkers are traditionally applied. Newer imaging technologies such as multi-slice computed tomography, photon-emission computed tomography, and magnetic resonance imaging might add value to conventional echocardiography in diagnosis and management of IE. Treatment consists of long-term antibiotic therapy, infectiological source control and/or cardiac surgery. Recently, antibiotic parenteral outpatient regimens and partial oral treatment strategies were shown to shorten hospital stays in patients suffering from IE. However, it remains unclear how to best select patients for partial oral therapy. This review describes new trends in diagnosing, imaging, and treating IE in a changing patient collective with particular focus on patients with implantable cardiac devices.

Risk stratification in stable coronary artery disease: superiority of N-terminal pro B-type natriuretic peptide over high-sensitivity C-reactive protein, gamma-glutamyl transferase, and traditional risk factors.

OBJECTIVE: The aim of the study was to compare N-terminal pro B-type natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein, and gamma-glutamyl transferase (γ-GT) with traditional risk markers for estimating prognosis in patients with stable coronary artery disease (CAD). MATERIALS AND METHODS: Evaluation of mortality and a combined clinical endpoint (mortality, need for coronary revascularization, myocardial infarction, hospitalization for cardiac causes, or stroke) during an average 3.2-year follow-up in 394 consecutive patients (73% male patients, age: 67±9 years) with angiographically proven stable CAD. RESULTS: Univariate Kaplan-Meier survival rate analysis showed that traditional risk markers, apart from impaired renal function, three-vessel CAD, and a reduced left ventricular function at the time of coronary angiography, were not of prognostic relevance for prediction of outcome. NT-proBNP, high-sensitivity C-reactive protein, and gamma-glutamyl transferase were significant predictors of mortality; however, only NT-proBNP was a significant predictor of the combined endpoint. In age-adjusted and sex-adjusted multivariate Cox regression analysis, NT-proBNP was the strongest independent predictor of the combined endpoint (odds ratio 2.92, 95% confidence interval: 1.72-4.94, first vs. third tertile). All three laboratory parameters remained independent risk markers for mortality in multivariate analysis. NT-proBNP, however, revealed the highest odds ratio (5.23, 95% confidence interval: 1.17-23.23, first vs. third tertile). Concentrations greater than 356 ng/l predicted mortality with a sensitivity of 70%, a specificity of 71%, a positive likelihood ratio of 2.4, and a negative likelihood ratio of 0.42. CONCLUSION: In comparison with other tested novel biomarkers and traditional risk markers, NT-proBNP was the most predictive prognostic marker in multivariate analysis in patients with stable CAD.