Cardi ac Emergenci es

Infective Endocarditis, Pericarditis, and Myocarditis

Tin Han Htwe, MD
a
, Nancy Misri Khardori, MD, PhD
b,c,
*
INTRODUCTION
Of all the medical specialties, cardiology has the most emergent situations. Noninfec-
tious cardiac emergencies are appreciated and managed appropriately in the emer-
gency department as well as the Intensive care unit. Although infectious cardiac
emergencies have somewhat less dramatic presentations, they can lead to significant
morbidity and mortality if not diagnosed early and managed appropriately. Because of
the involvement of infectious agents in cardiac emergencies, there is a need for
constant surveillance of common infectious agents and their resistance patterns to
be able to presumptively treat life-threatening cardiac infections. When and if cultures
do become available after 3 to 4 days, the selection of definitive antimicrobial therapy
becomes much easier. This article focuses on the epidemiology, microbiology, and
management of infective endocarditis (IE), pericarditis, and myocarditis. The
emphasis on the changing microbiology of IE deserves special consideration. The
treatment guidelines from The American Heart Association and the European Society
of Cardiology are reviewed.
a
Division of Infectious Diseases, Sentara Medical Group, 850 Kempsville Road, Norfolk, VA
23502-3979, USA;
b
Division of Infectious Diseases, Department of Internal Medicine, Eastern
Virginia Medical School, 825 Fairfax Avenue, Norfolk, VA 23507, USA;
c
Department of Micro-
biology and Cell Biology, Eastern Virginia Medical School, 825 Fairfax Avenue, Norfolk, VA
23507, USA
* Corresponding author.
E-mail address: [email protected]
KEYWORDS

Infective endocarditis

Pericarditis

Myocarditis

Congestive heart failure

Fever

Leukocytosis
KEY POINTS
Infective endocarditis is increasing in incidence.
Staphylococcus aureus as a cause of endocarditis is becoming more common in both
native valve and prosthetic valve endocarditis.
After initial supportive care and presumptive antimicrobial therapy, the results of blood
cultures and antimicrobial susceptibility should be used to optimize definitive therapy.
Most cases of acute pericarditis and acute myocarditis are caused by viruses.
Med Clin N Am 96 (2012) 11491169
http://dx.doi.org/10.1016/j.mcna.2012.09.003 medical.theclinics.com
0025-7125/12/$ see front matter 2012 Published by Elsevier Inc.
IE
As the name implies, IE is the term used for infection of endocardial surface of the
heart with formation of conglomerates made of bacteria and platelets (vegetations)
on the heart valves, even though it can also involve septal defects and mural
endocardium.
1
A Paradigm Shift
In the western world, the incidence of IE has been reported to 1.7 to 11.2 per 100,000
populations per year. The American Heart Association estimates about 100,000 to
200,000 annual new cases in the United States each year. The percentage of acute
IE cases has increased significantly compared with that in the preantibiotic era
(20% vs 75%).
1,2
In the past, IE was an indolent subacute illness occurring predominantly in patients
with underlying valvular disease. However, in the last 25 years the disease paradigm
has shifted to more acute presentation and lack of classical sings of infective endocar-
ditis. IE carries significant morbidity and mortality despite advances in diagnostic,
medical, and surgical interventions. IE-related in-hospital mortality ranges from 15%
to 20% and 1 year mortality can be up to 40%.
1,2
A prospective cohort study reviewed subjects admitted with a diagnosis of IE in 25
countries fromJune 2000 to September 2005. The results showed changing pattern of
clinical presentation of IE and its microbiology. Most of the subjects with IE presented
with an acute illness (<30 days) and Staphylococcus aureus was the most common
pathogen. Mitral and aortic valves were most commonly involved. Predisposing
factors for IE were the subject being an intravenous drug user (IVDU), degenerative
valvular disease, and indwelling venous catheters. In-hospital mortality was approxi-
mately 18%and it was higher in subjects with older age, prosthetic valve endocarditis,
mitral valve vegetations, paravalvular involvement, pulmonary edema, and staphylo-
coccal causes. About 5% of subjects required surgical intervention. Early surgical
intervention and viridan streptococcal causes had better outcomes. The most
common complication was heart failure (32%), embolization (22%), stroke (17%),
and intracardiac abscess (14%).
2
Three successive population-based studies in France (1991, 1999, and 2008)
showed no increase in overall incidence of infective endocarditis or streptococcal
endocarditis after scaling down of the antibiotic prophylaxis for dental procedures.
However, there was a marked rise in staphylococcal endocarditis with both native
and prosthetic valves observed.
3
This paradigm shift in the cause of IE is thought to be due to increasing medical
comorbidities and more exposure to the health care environment.
4
A recent study in the Czech Republic showed that the crude incidence of IE was 3.4
cases per 100,000 inhabitants per year. Vegetations were most frequently found on
the aortic and mitral valves. The most common organism was S aureus (29.9%).
Skin and soft tissue infections (13%) and hemodialysis catheter infections (8.2%)
were common precursors to IE. Predisposing factors included remote cardiac surgery
(19.4%) and degenerative valvular changes (11.9%). In-hospital mortality rate was
27.5%. Surgical intervention during antibiotic therapy was performed in 36 subjects
(27.5%). Nearly 39% of total IE episodes (134) occurred in subjects with cardiac
and noncardiac medical procedures and devices.
5
A recent large cohort study at a university system in France followed 847 subjects
with definite diagnosis of IE over 11 years (2000 to 2011). They reported a mortality
rate of 22.5%, IE-related mortality was 15.9%. Sudden death over a 6-month period
Htwe & Khardori 1150
occurred in 2.7% of patients with IE treated medically. Sudden death was associated
with diabetes mellitus, signs of heart failure at admission, and severe comorbidities.
Most cases were caused by Streptococcus spp. Sudden death was caused by acute
myocardial infarction (AMI), cardiac tamponade, perivalvular extension, myocardial
abscess with free wall perforation, and malignant arrhythmia.
6
MICROBIOLOGY
Gram-positive organisms remain the predominant cause of infective endocarditis.
A retrospective Canadian study in 1996 reported the microbial causes of IE as Strep-
tococci (43%), Staphylococci (30%), and Enterococci (5%). Gram-negative organisms
accounted for 10%of native valve endocarditis. The most common organismin IDVUs
was S aureus (40%), followed by Pseudomonas aeruginosa (13%) and polymicrobial
causes (27%), and the remaining were culture negative. Early prosthetic valve endo-
carditis is caused mostly by coagulase-negative Staphylococci (CNS). The microbio-
logical spectrum of late prosthetic valve endocarditis is broader and includes
organisms that cause native valve endocarditis and those that cause early prosthetic
valve endocarditis.
7
Tricuspid valve is more commonly involved in IDVUs (73%). But left-sided IE with
polymicrobial infection and systemic embolization are also on the rise in this
population.
7,8
A recent large international prospective cohort study showed S aureus to be the
most common pathogen (31%), followed by Streptococci (17%) and CNS (11%) in
IVDUs.
2
A review of endocarditis in IVDUs describes polymicrobial infections composed of
S aureus, Streptococcus pneumoniae, P aeruginosa, and mixed infections with
Candida spp and other rare bacteria depending on the type of drugs abused. P aeru-
ginosa infection is strongly associated with pentazocine-tripelennamine usage.
Candida spp are associated with brown heroin dissolved in lemon juice. Human oral
cavity normal flora such as Haemophilus influenzae, Eikenella corrodens, and Strepto-
coccus milleri can play a role in IE related to intravenous (IV) drug use due to habitual
cleaning of needles with saliva.
8
The use of a cardiovascular implantable electronic device is another factor respon-
sible for the increase in staphylococcal infections. S aureus and CNS caused 29%and
42% of IE in this subject population. The pathogenesis of infections related to the
devices is the adherence and biofilm formation by Staphylococci and infections
caused by small colony variant S aureus.
911
IE caused by S aureus shows increasing incidence as well as mortality over the past
50 years.
12
The highest increase of staphylococcal IE in the United States is due to
chronic hemodialysis access, more people with diabetes mellitus, and increased
use of intravascular devices.
13,14
Coagulase negative staphylococcal infections of prosthetic valves cause higher
mortality and more virulent complications such as heart failure and valvular abscess
formation.
15
More aggressive CNS strains such as S lugdunensis can cause severe
IE of native valves resulting in fatal outcomes despite appropriate antimicrobial
therapy and surgical intervention. Therefore, early surgical intervention must be
considered, particularly for the S lugdunensis IE.
16
A recent international collaborative study involving 2751 subjects in 61 hospitals in
28 countries reported that nonHaemophilus aphrophilus, Actinobacillus actinomyce-
temcomitans, Cardiobacterium hominis, Eikenella corrodens, and various species of
Kingella (HACEK) gram-negative organisms are responsible for less than 2% cases
Cardiac Emergencies 1151
of IE. The most common predisposing factor was health carerelated infections
(>50%), which included indwelling cardiac devices. Patients with prosthetic valves
and IVDUs formed a minority of the group. Escherichia coli (29%) was the most
common non-HACEK gram-negative organism, followed by P aeruginosa (22%).
17
IE caused by P aeruginosa was also reported in subjects on hemodialysis and renal
transplant recipients with bacteremia.
18,19
Candida endocarditis has high mortality rate and usually has a fatal outcome. Risk
factors for IE caused by Candida spp are heroin use, immunosuppression, indwelling
venous catheters, prosthetic valves, and recent cardiac surgery. Candida albicans
(48%) is the most common species followed by C parapsilosis (21%), C glabarata
(15%), C tropicalis (9%), and unspeciated Candia (6%). More than 50% of these infec-
tions were health careassociated.
20,21
ACUTE CARDIOVASCULAR COMPLICATIONS
Acute cardiovascular complications of IE are usually related to vegetations. Vegeta-
tions in IE are composed of deposits of bacteria, fibrin, and platelets. They are usually
found along the line of closure of a valve leaflet on the atrial surface of atrioventricular
valves or on the ventricular surface of semilunar valves. Vegetations can be solitary or
multiple. In acute IE, vegetations are more friable, softer, and tend to be necrotic and
suppurative compared with those in subacute IE. Vegetations can cause destruction
of heart structures with perforation of the valve leaflet or rupture of the chordae tendi-
nae, interventricular septum, or papillary muscle. Valve ring abscesses can lead to
fistula formation into the myocardium and pericardial space.
Myocardial abscesses, myocardial infarction, myocarditis are complications
commonly associated with acute staphylococcal IE.
Mycotic aneurysms are often seen at bifurcation points of vessels, including the
sinus of Valsalva; a ligated patent ductus arteriosus; and the splenic, coronary, pulmo-
nary, superior mesenteric, and cerebral arteries. These develop during the acute
phase of IE but remain dormant until they rupture and cause embolization. They are
usually associated with streptococcal infections.
1
Generally, IE presents with insidious onset of nonspecific vague symptoms that
include malaise, generalized weakness, low-grade fever, and arthralgia. However, IE
can present with serious and potentially fatal acute cardiovascular symptoms,
including acute chest pain syndrome, acute decompensated congestive heart failure,
malignant arrhythmia, and acute respiratory failure.
The most common serious presentation of S aureus IE is congestive heart failure,
which can be an initial presentation or develop during the course of illness. In a retro-
spective survey, it was commonly reported with left-sided IE (49%) and rarely seen in
right-sided IE (3%). Other rare but serious cardiovascular complications include
myocardial abscesses (mostly in left-sided prosthetic valve IE), atrioventricular block,
acute coronary syndrome, aortocavitary fistulous tract formation, and pericarditis.
12
Mitral valve is more commonly involved than aortic valve in left-sided IE. Left-sided
IE has a much higher mortality than right-sided IE (38% vs 17%) owing to an associ-
ation with systemic embolization and multiorgan failure. Right-sided IE occurs in
patients with IVDUs and vascular catheter-related bacteremia.
12
AMI can occur in the setting of the acute phase of IE because of embolization of
coronary arteries from the aortic valve vegetations, decreased blood flow from valve
insufficiency, or blockage of coronary ostiumby large vegetation. Most of the coronary
embolization in patients with acute IE involves the left anterior descending artery. It
can rarely cause transmural myocardial infarction. A case series of two subjects
Htwe & Khardori 1152
describes a young subject with AMI and Lactobacillus jensenii mitral valve vegetation
complicated by left ventricular apical thrombus, which required anticoagulation. The
second subject was a 40-year-old IVDU with patent foramen ovale and IE involving
both mitral valve and tricuspid valve due to methicillin-susceptible S aureus (MSSA).
IE was complicated by pulmonary septic emboli, pericardial and pleural effusion,
multiple brain embolic abscesses, and later by pseudoaneurysm arising from the infe-
rior septal wall of left ventricle that needed surgical repair. The authors reviewed
13 other documented cases of AMI in the setting of acute IE. Organisms involved
were Streptococci, Enterococci, Staphylococci, and Lactobacilli.
22
Treatment of AMI in this setting is controversial. Thrombolytic therapy is not recom-
mended because of higher risk of intracerebral hemorrhagic complications. Urgent
percutaneous coronary intervention is the preferred option but definitive treatment
should be individualized.
2225
Sudden death can be caused by perforation of the free wall myocardial abscess of
the left ventricle leading to hemopericardium, which is a rare complication of staphy-
lococcal IE.
26
In a retrospective multicenter review of 2055 cases of native aortic valve IE, perian-
nular extension of infection occurred in 9.8% of subjects. The incidence of heart
failure, ventricular septal defect, and third-degree atrioventricular block were higher
in subjects with aortocavitary fistulization compared with nonruptured abscess.
Most subjects (86%) required surgical intervention carrying in-hospitality mortality of
29%.
27
The International Collaboration on Endocarditis Merged Database (ICE-MD)
describes 311 subjects with aortic valve IE of which 22% had periannular abscess
formation. S aureus was an independent risk factor for abscess formation.
28
A subject with patent ductus arteriosus developed aortic valve IE, which extended
to the sinus of Valsalva and pericardium, leading to pericarditis, cardiac tamponade,
and systemic septic embolization.
29
A case of endocarditis caused by group A Streptococcus presented with fever,
pharyngitis, and acute renal failure due to glomerulonephritis without valvular vegeta-
tion and later developed heart failure. The subject had several peripheral stigmata of
IE, which included Janeway lesions and splinter hemorrhages.
30
Group A streptococcal endocarditis has been reported in association with IVDU and
in children following varicella infections. It more commonly affects the right side of the
heart with embolic phenomena.
3134
DIAGNOSIS
Clinical Symptoms and Signs
The most common presentation of IE is fever accompanied by nonspecific symptoms
of chills, generalized weakness, arthralgia, and poor appetite. However, fever can be
absent in the elderly, immunosuppressed patients, and in patients with prior antibiotic
use. Acute IE presents with rapid progression of very high fever and embolic
phenomena. Septic pulmonary emboli can present as acute respiratory failure with
pleuritic chest pain and hemoptysis. Cardiovascular emboli and valvular dysfunction
can present as acute chest pain mimicking AMI and heart failure. Acute abdominal
pain can be seen in splenic infarct, and hematuria and acute renal failure occur with
renal infarct and glomerulonephritis. Classic peripheral cutaneous signs are usually
absent in acute IE, except embolic lesions involving the extremities.
Acute IE should be suspected in patients who are IVDUs, with new onset of murmur,
intracardiac devices, indwelling vascular devices, positive blood cultures with
Cardiac Emergencies 1153
organisms known tocause IE, underlyingvalvular diseases, emboliclesions of unknown
source, immunocompromisedconditions, previoushistory of IE, newconductiondistur-
bances, peripheral organ abscesses, and focal and nonspecific neurologic deficits.
Clinical diagnosis of IE is usually based on modified Duke criteria.
Major criteria include
1
positive blood cultures with IE-related pathogens from(1) two
separate blood cultures, (2) at least two positive blood cultures drawn more than
12 hours apart, (3) all of three blood cultures, (4) a majority of more than four separate
blood cultures (first and last sample drawn a minimum of 1 hour apart),
2
or (5) echo-
cardiographic evidence of IE. Minor criteria include fever, vascular and immunologic
phenomena, predisposing heart conditions or IV drug use, and positive blood cultures
not meeting the major criteria.
Definitive IE is defined as the presence of two major criteria, one major and two
minor criteria, or five minor criteria.
Laboratory
Abnormalities in routine laboratory studies finding include elevated leukocyte count
with left-shift C-reactive protein or sedimentation rate, anemia, and microscopic
hematuria.
Microbiology
Three sets of blood cultures (each set should contain both aerobic and anaerobic
bottles with at least 10 mL of blood in each bottle) should be drawn from peripheral
sites before starting antimicrobial therapy in the first 24 hours. Cultures should not
be delayed awaiting a fever spike. Obtaining blood samples from central venous cath-
eters is not recommended. Negative blood cultures after 5 days of intubation need
subculture on specialized media. Repeating blood cultures on day 1 and day 3 after
starting antimicrobial therapy is recommended.
Echocardiography
Echocardiogram is the main stay of diagnosis in IE. It should be performed in less than
12 hours after presentation in patients suspected to have IE. Transesophageal echo-
cardiogram (TEE) is more sensitive than transthoracic echocardiogram (TTE) for
abscess and vegetation; however, cost and accessibility might be limiting factors.
TTE should be performed in every suspected case of IE. TEE should be performed
in patients with no abnormal finding on TTE when the clinical index of suspicion for
IE is high, such as staphylococcal bacteremia, valve replacement, and patients with
chronic hemodialysis access.
If initial TEE in patients with high probability of IE is negative or indeterminate, it
should be repeated in 7 to 10 days. In addition to vegetation, echocardiogram can
detect abscess, dehiscence of prosthetic valve, and dysfunction of a native valve.
TEE or TTE should be repeated during the course of treatment in the presence of
persistent bacteremia, development of heart failure, or conduction abnormality.
A repeat TEE or TTE may be useful for detection of clinically silent complications,
especially if the size of vegetation at the baseline is large. A repeat echocardiogram,
usually TTE is recommended at the completion of treatment to establish new base line
and to compare with initial findings.
1,21,35
A prospective review of 103 subjects with S aureus bacteremia showed the superi-
ority of TEE in the diagnosis of IE. The sensitivity of TTE versus TEE to detect IE in this
subject population was 32% versus 100%. TEE detected evidence of IE in 19% of
subjects with a negative and 21% of subjects with an indeterminate TTE.
36
Htwe & Khardori 1154
In a report of 19 cases of valvular perforation in acute IE, TEE had better diagnostic
sensitivity (95%) versus 45% for TTE in detecting this complication.
37
A recent review article recommend TEE in staphylococcal bacteremia in the setting
of fever and prolonged bacteremia (>3 days); prosthetic valves or intracardiac devices;
embolic or cutaneous manifestations; or relapse of staphylococcal bacteremia.
38
About a quarter (25%) of vegetations seen on TEE in patients with left-sided IE are
mobile and larger than 10 mm. They tend to produce new emboli after initiation of anti-
microbial therapy. Vegetations produced by Staphylococci and nonviridan Strepto-
cocci are more likely to cause embolization.
39
MANAGEMENT
Antimicrobial Therapy
The Tables 14 list the antibiotic agents recommended for treatment of IE based on
the organism grown and the type of valve involved.
Staphylococcal Infections
For IE caused by MSSA, nafcillin or cefazolin is the recommend therapy. Vancomycin
is still the recommend therapy for IE caused by methicillin-resistant S aureus (MRSA)
in the current guidelines. However, vancomycin failures have been reported with high
minimum inhibitory concentrations (MICs) greater than 1 mg/mL.
21,35
Daptomycin is a cyclic lipopeptide bactericidal antibiotic that is non-inferior to stan-
dard treatment with vancomycin plus low-dose gentamicin for S aureus bacteremia
and right-sided endocarditis.
40,41
A retrospective case control study showed that daptomycin offers better clinical
and microbiological outcome in the treatment of MRSA blood stream infection with
strains that have vancomycin MICs greater than 1 mg/mL.
42
Addition of low-dose initial aminoglycoside to an antistaphylococcal beta-lactam,
vancomycin, or daptomycin has shown variable results.
Current guidelines recommend optional addition of gentamicin for first 3 to 5 days of
treatment. However, a prospective cohort study showed that low-dose gentamicin
therapy (1 mg/Kg every 8 hours) for first 4 days leads to nephrotoxicity and should
not be used routinely.
43
Table 1
Presumptive (initial) antibiotic therapy for native valve endocarditis and prosthetic valve
endocarditis (>12 months)
Antimicrobial Dosage Duration
Vancomycin
or
Ampicillin-sulbactam
or
Ampicillin-clavulanate
plus
Gentamicin
30 mg/kg/24 h IV in 2 divided doses
12 g/d in 4 divided doses
Same as ampicillin-sulbactam
3 mg/kg/d in 2 or 3 divided doses
46 wk
Patients allergic or intolerant to penicillin:
Vancomycin
plus
Gentamicin
plus
Ciprofloxacin
30 mg/kg/24 h IV in 2 divided doses
Same as above
1000 mg/d oral in 2 divided doses
or
800 mg IV in 2 divided doses
46 wk
Cardiac Emergencies 1155
A study using animal pharmacodynamic modeling showed that addition of a single
high-dose of gentamicin to vancomycin or daptomycin at the start of antimicrobial
therapy clears bacteremia faster.
44
Streptococcal Infections
For S pneumoniae and group A Streptococcusassociated IE caused by highly peni-
cillin sensitive strains, 4 week of therapy with penicillin G or first-generation or third-
generation cephalosporins is recommend. Vancomycin is recommended for penicillin
allergic and/or intolerant patients.
For streptococcal pneumoniae strains that are relatively resistant to penicillin (MICs
between 0.1 and 1 mg/mL) and highly resistant to penicillin (MICs >2 mg/mL), third-
generation cephalosporins can still be used. With meningeal involvement, third-gener-
ation cephalosporins are recommended in all patients because of better penetration
into central nervous system. For cefotaxime-resistant strains with MICs >2 mg/mL
with meningeal involvement, addition of vancomycin and rifampin should be consid-
ered. Usual recommended duration for S pneumoniae IE is 4 weeks.
For IE due to Streptococcus Group A, B, C, G, and S milleri group, the addition of an
aminoglycoside for first 2 weeks is recommended owing to increasing resistance to
penicillin.
21,35
P aeruginosa Infections
Treatment of IE caused by P aeruginosa can be challenging. In a study of 11 subjects
with endocarditis caused by P aeruginosa, eight subjects were treated with antimicro-
bial combinations and three subjects with monotherapy with an aminoglycoside.
Surgical intervention was needed in 55% of subjects. Postsurgical complication rates
and in-hospital mortality rates were 73% and 36%, respectively. Surgery or antimicro-
bial treatment did not improve the outcome significantly.
17
Treatment regimens for IE caused by P aeruginosa are based on clinical experience
and no large clinical trial has been performed. American Heart Association guidelines
recommend antipseudomonal beta-lactamantibiotics (cefepime, imipenem-cilastatin,
ticarcillin, piperacillin, azlocillin, ceftazidime, or cefepime in full doses) with high-dose
tobramycin (tobramycin (8 mg/kg/d IV). It is recommended to maintain peak and
trough concentrations of 15 to 20 mg/L and 2 mg/L, respectively.
35
Successful treatment with combination therapy with imipenem-cilastatin plus ami-
kacin and imipenem-cilastatin plus ciprofloxacin has been reported in renal transplant
recipients.
18
Minimum recommended duration of treatment with the combination regimen is
6 weeks. Toxicity with this regimen is reported to be low. Successful treatment with
initial combination followed by monotherapy has been reported.
35
Table 2
Presumptive (initial) antibiotic therapy for prosthetic valve endocarditis (<12 months)
Antimicrobial Dosage Duration
Vancomycin
plus
Gentamicin
plus
Rifampin
30 mg/kg/24 h IV in 2 divided doses
3 mg/kg/d in 2 or 3 divided doses
1200 mg/d in 2 divided doses
6 wk
2 wk
Vancomycin recommended trough is 10 to 15 mg/L and peak is 30 to 45 mg/L.
Htwe & Khardori 1156
Table 3
Definitive (organism-based) antibiotic therapy for native valve endocarditis
Organisms Antimicrobial Regime Duration of Therapy
MSSA Nafcillin or oxacillin 12 g/24 h IV in 46
equally divided doses
Optional
Gentamicin (3 mg/kg/d in 2 or 3 divided
doses)
Patients unable to tolerate nafcillin or
oxacillin (nonanaphylaxis)
Cefazolin 6 g/24 h IV in 3 equally divided
Optional
Gentamicin (same dose as mentioned
above)
6 wk
(2 wk for uncomplicated
right-sided IE)
35 d
6 wk
35 d
MRSA
or
Patients unable to tolerate
oxacillin or nafcillin
with anaphylactic conditions
Vancomycin 30 mg/kg/ 24 h IV in 2 equally
divided doses
6 wk
Enterococci spp
sensitive to penicillin,
gentamicin, and
vancomycin
Ampicillin sodium 12 g/24 h IV in 6 equally
divided doses
or
Aqueous crystalline penicillin G 1830
million U/24 h IV either
continuously or in 6 equally divided
doses
plus
Gentamicin (dose as mentioned above)
Patients unable to tolerate penicillin or
ampicillin
Vancomycin (dose as mentioned above)
plus
Gentamicin (dose as mentioned above)
46 wk
46 wk
6 wk
6 wk
6 wk
Enterococci spp
susceptible to
penicillin,
streptomycin, and
vancomycin; and
resistant to gentamicin
Ampicillin (dose as mentioned above)
or
Aqueous crystalline penicillin G (dose as
mentioned above)
plus
Streptomycin 15 mg/kg/ 24 h IV/IM in 2
equally divided doses
Patients unable to tolerate penicillin or
ampicillin
Vancomycin (dose as mentioned above)
plus
Streptomycin (dose as mentioned above)
46 wk
(4 wk for patient with
symptoms <3 mo)
46 wk
(4 wk for patient with
symptoms <3 mo)
6 wk
6 wk
Enterococci strains
resistant to
penicillin and
susceptible to
aminoglycoside
and vancomycin
Beta-lactamaseproducing strain
Ampicillin-sulbactam 12 g/24 h IV in 4
equally divided doses
plus
Gentamicin (dose as mentioned above)
Penicillin resistant strains
Vancomycin (dose as mentioned above)
plus
Gentamicin (dose as mentioned above)
6 wk
(>6 wk for gentamicin
resistant strains)
6 wk
(continued on next page)
Cardiac Emergencies 1157
Combination therapy with fluoroquinolones and aminoglycosides has shown prom-
ising results in animal models and human cases but development antibiotic resistance
is the limiting factor.
45
In a rabbit model, left-sided IE caused by P aeruginosa showed better outcome with
a combination of ceftazidime and amikacin compared with monotherapy with ceftazi-
dime or aztreonam. Addition of amikacin to aztreonam did not make a statistically
significant difference.
46
Table 3
(continued)
Organisms Antimicrobial Regime Duration of Therapy
Enterococci strains
resistant to penicillin,
aminoglycoside, and
vancomycin
E faecium, linezolid 1200 mg/24 h
IV/PO in 2 equally divided doses
or
Quinupristin-dalfopristin 22.5 mg/kg/
24 h IV in 3 equally divided doses
E faecalis imipenem/cilastatin 2 g/24 h
IV in 4 equally divided doses
plus
Ampicillin (dose as mentioned above)
or
Ceftriaxone sodium 4 g/24 h IV/IM in 2
equally divided doses
plus
Ampicillin (dose as mentioned above)
Minimum 8 wk
Minimum 8 wk
Minimum 8 wk
Minimum 8 wk
Minimum 8 wk
Streptococcal strains
Highly penicillin-susceptible
viridians group Streptococci
and Streptococcus bovis
Aqueous crystalline penicillin G (dose
as mentioned above)
or
Ceftriaxone sodium 2 g/24 h IV/IM in 1
dose
or
Aqueous crystalline penicillin G (or)
Ceftriaxone (doses as mentioned
above)
plus
Gentamicin (dose as mentioned)
Patients unable to tolerate penicillin
or ceftriaxone
Vancomycin (dose as mentioned
above)
4 wk
4 wk
4 wk
2 wk
4 wk
Viridan group streptococci
and Streptococcus bovis
relatively resistant to
penicillin (MIC >0.12 mg/mL
and <0.5 mg/mL)
Aqueous crystalline penicillin G (dose
as mentioned above)
or
Ceftriaxone (dose as mentioned
above)
plus
Gentamicin (see above)
Patients unable to tolerate penicillin
or ceftriaxone
Vancomycin (see above)
4 wk
4 wk
2 wk
4 wk
Viridan group Streptococci
and Streptococcus bovis
resistant to penicillin
(MIC >0.5mg/mL)
Use the same regimen as for penicillin
resistant Enterococci spp

Abbreviations: IM, intramuscular; MRSA, methicillin-resistant S aureus.

Htwe & Khardori 1158
Table 4
Definitive (organism-based) antibiotic therapy for prosthetic valve endocarditis
Microorganism Antimicrobial Regime
Duration of
Therapy
MSSA Nafcillin or oxacillin 12 g/24 h IV in 6 equally divided
doses
or
Cefazolin 6 g/24 h IV in 3 equally divided doses
or
Penicillin G 24 million U/24 hr in 46 divided doses (for
strains with MIC <0.1 mg/mL and nonbeta-lactamase
producing
plus
Rifampin 900 mg/ 24 h IV/po in 3 equally divided doses
plus
Gentamicin 3 mg/kg/ 24 h IV/IM in 2 or 3 equally divided
doses
6 wk or longer
6 wk or longer
6 wk or longer
2 wk
MRSA
(or)
Penicillin allergic
patients with
anaphylactic
conditions
Vancomycin 30 mg/kg/ 24 h in 2 divided doses
plus
Rifampin 900 mg/24 h IV/PO in 3 equally divided doses
plus
Gentamicin 3 mg/kg/ 24 h IV/IM in 2 or 3 equally divided
doses
6 wk or longer
6 wk or longer
2 wk
Enterococci spp
sensitive to
penicillin,
gentamicin
and vancomycin
Ampicillin sodium 12 g/24 h IV in 6 equally divided
or
Aqueous crystalline penicillin G
1830 million U/24 h IVeither continuously or in 6 equally
divided doses
plus
Gentamicin sulfate 3 mg/kg/ 24 h IV/IM in 3 equally
divided doses
Patients unable to tolerate penicillin or
ampicillin
Vancomycin (doses as mentioned above)
plus
Gentamicin (doses as mentioned above)
46 wk
46 wk
2 wk
6 wk
6 wk
Viridans group
streptococci and
Streptococcus
bovis
Penicillin sensitive strains (MIC <0.12 mg/mL)
Aqueous crystalline penicillin G (dose as mentioned)
or
Ceftriaxone 2 g/24H IM /IV
Optional
Gentamicin (dose as mentioned above)
Patients unable to tolerate penicillin or
ampicillin
Vancomycin (dose as mentioned above)
Penicillin fully or relatively resistant strains
(MIC >0.12 mg/mL)
Aqueous crystalline penicillin G (dose as mentioned
above)
or
Ceftriaxone (dose as mentioned above)
plus
Gentamicin (dose as mentioned above)
Patients unable to tolerate penicillin or
ceftriaxone
Vancomycin (dose as mentioned above)
6 wk
6 wk
2 wk
6 wk
6 wk
6 wk
6 wk
6 wk
Adapted from AHA and ESC guidelines Habib G, Hoen B, Tornos P, et al. Guidelines on the preven-
tion, diagnosis, and treatment of infective endocarditis. Eur Heart J 2009;30(19):2369413; and
Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis: diagnosis, antimicrobial therapy,
and management of complications. Circulation 2005;111(23):e394434.
1159
Candida Infections
European Society of Cardiology guidelines recommend amphotericin B for 6 to 8
weeks to treat IE caused by Candida spp. This should be followed by fluconazole
for long-term suppression because of a high relapse rate.
21
The most recent guidelines from Infectious Disease Society of America recommend
primary therapy for Candida IE to be amphotericin B (liposomal or traditional) with or
without addition of 5-flucytosine or an echinocandin. Step-down therapy with flucona-
zole is recommended after the susceptibility is available. Valve replacement is strongly
recommended and lifelong suppression with fluconazole is recommended in poor
surgical candidates.
47
American Heart Association guidelines also recommend two phases of therapy. The
initial phase is to control the candidemia with combination antifungal therapy for
a minimum of 6 weeks and valve replacement. Suppression therapy is recommended
for patients at risk for valve replacement. Valve replacement is strongly recommended
in fungal endocarditis of prosthetic valves.
35
In an international prospective study of IE caused by Candida spp (33 subjects),
Amphotericin B was the most commonly used antifungal agent (59%), followed by
fluconazole (44%) and echinocandins (37%). Combination therapy was used in only
two cases. Mortality rates were similar between combination treatment (surgery and
antifungal) and antifungal treatment alone (33.3% vs 27.8%).
20
A case report of relapsing C parapsilosis endocarditis in an IVDU and review of
71 cases in the literature showed risk factors for C parapsilosis to be prosthetic valve
endocarditis (57%), followed by the patients being an IVDU (20%). Amphotericin B
was used to treat most cases (57%), caspofungin was used in 4.1%, and voriconzole
in 2.7%. Thirty-eight percent of subjects received single-agent therapy, whereas 35%
received combination treatment, and 22% received sequential treatment. Current
guidelines recommend valve replacement in fungal endocarditis regardless of the
type of valve.
48
A case of prosthetic valve infective endocarditis due to C glabrata was successfully
treated with a combination of fluconazole and caspofungin without surgical interven-
tion. The patient was initially treated with a combination of fluconazole and IV ampho-
tericin B but developed renal toxicity after a short period, after which the amphotericin
B was discontinued. However, because of persistent fungemia, caspofungin was
added to fluconazole at 6 weeks. This was followed by lifelong suppression with
fluconazole.
49
Surgical treatment
The indications for surgical intervention in IE
1
are (1) heart failure despite medical treat-
ment and development of acute severe valvular regurgitation leading to pulmonary
edema or cardiogenic shock
2
; (2) persistent infection locally with development of
valvular abscess, insufficiency, or perforation and fistula formation; (3) infection
systemically with uncontrolled fever and persistent bacteremia (710 days)
3
; or
(4) fungal infections and infections caused by multidrug resistant organisms.
4
Large
vegetations (>10 mm) and enlarging vegetations despite antimicrobial therapy to
prevent embolization are also indications for surgical intervention.
21,35
In a retrospective study of S aureus endocarditis, valve replacement significantly
reduced the mortality in left-sided prosthetic valve endocarditis.
18
Emergency surgical intervention for acute mitral valve endocarditis presenting with
cardiogenic shock also improved outcome.
50
Timing of surgery for patients who have
met the clinical and echocardiographic criteria for surgical intervention is still contro-
versial. A recent Korean study showed that early preemptive surgery in subjects with
Htwe & Khardori 1160
acute left-sided native valve IE with severe valvular disease and large vegetations
(10 mm or larger) causes significant reduction in embolization risk (one subject in
surgery arm vs eight subjects treated medically). The subjects were taken for surgery
within 48 hours of diagnosis.
51
ACUTE PERICARDITIS
Introduction
Acute pericarditis is the inflammation of fibrous tissue layer surrounding the heart and
base of great vessels. It usually presents as acute chest pain in adults. It is important to
recognize the clinical syndrome because the complications of pericarditis can be as
serious as cardiac tamponade or pericardial effusion leading to heart failure and death.
Diagnosis is based on characteristic chest pain and electrocardiographic changes
with or without pericardial rub on auscultation. However, establishing the cause can
be challenging because most cases turn out to be idiopathic despite extensive
work-up.
52
Causes and Incidence
Causes of acute pericarditis can be simply divided into infectious and noninfectious.
Infectious causes are mostly viral (most commonly echovirus and coxsackieviruses
A and B), accounting for 90% of cases (Table 5). Other causes include bacteria
S pneumoniae, MRSA, and Mycobacterium tuberculosis in patients with HIV.
52
Table 5
Reported pathogens in acute infectious pericarditis
Viruses Coxsackievirus A and B
Echovirus
Hepatitis B, Hepatitis C
Epstein- Barr virus
Cytomegalovirus virus
Adenovirus
HIV
HHV-6
Parvovirus B19
Influenza
Measles
Mumps
Varicella
Bacteria Gram-positive: S aureus, S pneumoniae, S pyogenes, S agalactiae, Listeria spp
Gram-negative: H influenzae, P aeruginosa, and other species, Neisseria
meningitidis, E coli, Salmonella typhi, K pneumoniae, P miribalis
Mycoplasma spp, Chlamydia spp, Legionella spp, Bordetella holmesii
Anaerobes: Clostridium spp, Actinomyces spp, Bacteroides spp,
Propionibacterium spp
Mycobacterium tuberculosis
Fungi Candida spp, Aspergillus spp, Blastomyces dermatitidis immunocompromised
patients
Histoplasma capsulatum (in immunocompetent patients)
Parasites Echinococcus granulosus
Toxoplasma gondii
Data from Refs.
5256
Cardiac Emergencies 1161
Most cases of bacterial (purulent) pericarditis reported in the literature are caused by
gram-positive organisms (64%), gram-negative organisms (27%), polymicrobial infec-
tions (2.3%), Candida spp (1.1%), Aspergillus spp (0.3%), and other miscellaneous
species (4.4%). S aureus (56%) is the most common bacterial pathogen followed by
S pneumoniae (33%). In the gram-negative group, H influenzae (45%) is the leading
organsim.
56
Saureus pericarditis occurs mostly in patients with infective endocarditis.
57
The incidence of pericarditis caused by Spneumoniae has decreased dramatically in
recent years; however, it can still cause acute purulent pericarditis leading to cardiac
tamponade, especially in immunosuppressed patients with underlying malignancy.
58
Other risk factors for purulent pericarditis in the postantibiotic era include recent
thoracic surgery, chronic kidney disease, alcohol abuse, and rheumatoid arthritis.
56
A triad of meningitis, pneumonia, and endocarditis (Austrian triad) complicated by
suppurative pericarditis and cardiac tamponade has been reported in an immunocom-
petent patient.
59
There are case reports of pericarditis caused by Clostridium sordellii in the pediatric
population and Listeria monocytogenes and Bordetella holmesii in immunocompro-
mised patients with malignancy.
6062
Tuberculous pericarditis is most commonly seen in developing countries, especially
in Africa. HIV infection accounts for up to 85% of these cases.
63
Clinical Presentation
The most common clinical presentation is acute onset of sharp stabbing retrosternal
chest pain, which is pleuritic in nature, worsened by inspiration and supine position
and relieved by sitting up and leaning forward. Pain radiates to one or both trapezius
muscle ridges. Patients usually have high-grade fever.
The most salient clinical sign in pericarditis is high-pitched frictional rub that is most
audible at the left parasternal border and best heard in the leaning-forward position at
the end of expiration.
Tachycardia, hypotension, and pulsus paradoxus (a decrease in systolic arterial
pressure of more than 10 mm Hg with inspiration) can be seen in cardiac tamponade,
which is an indication for urgent echocardiogram and pericardiocentesis.
52
Cardiac tamponade is more common in bacterial and neoplastic pericarditis
compared with that caused by virus.
54
Pericarditis has been reported in 21 cases in the past 40 years in patients diagnosed
withinfectiveendocarditis. Theaorticvalvewas mostly involvedandunderlyingmedical
comorbidities included diabetes mellitus type 2, and alcohol or substance abuse.
57
Diagnosis
The characteristic electrocardiographic finding in pericarditis is widespread concave
ST-segment elevation and PR-segment depression. Chest radiography can show car-
diomegaly if the pericardial effusion is large enough (>250 mL). Echocardiography
confirms the diagnosis and evaluates the extent of disease. In addition to leukocy-
tosis, elevated sedimentation rate and serum C-reactive protein level, and elevated
troponin levels are seen during initial work-up. HIV and antinuclear antibody testing
is recommend. Serologic testing for other viruses does not alter management.
Pericardiocentesis is indicated in pericardial tamponade, recurrent pericarditis, and
in patients who fail medical therapy for both diagnostic and therapeutic purposes.
The fluid should be sent for cell counts, triglycerides; cytology; and bacterial, fungal,
and mycobacterial cultures. An elevated adenosine deaminase level and polymerase
chain-reaction assay offer earlier diagnosis in patients with a high index of suspicion
Htwe & Khardori 1162
for Mtuberculosis pericarditis. Thoracocentesis is recommended if there is associated
pleural effusion.
52
Management
Indications for hospitalization for acute pericarditis include fever, large pericardial effu-
sion, suspected cardiac tamponade, immunosuppressed conditions, anticoagulation,
and myocarditis with elevation of troponin.
54
The mainstay for symptomatic treatment of pericarditis is nonsteroidal antiinflamma-
tory agents (NSAIDs) and colchicine. The use of glucocorticosteroids in the treatment
of acute pericarditis is controversial. In general, they are recommended for recurrent
episodes and severe cases not relieved by NSAIDs and colchicine. Specific antimicro-
bial treatment should be tailored if and when an infectious agent is identified.
52
Prognosis
Pericarditis generally is self-limited but complications, especially cardiac tamponade,
can have poor outcome. Recurrence can occur in up to 24% of patients, which is
common in the early course of the disease (2 weeks) but usually less severe in the
initial episode.
54
Purulent pericarditis carries a high mortality rate, especially if the diagnosis is
delayed.
The mortality rate is also higher in patients with both purulent pericarditis and IE
(60%).
63
Even in the setting of appropriate treatment, mortality is around 40%.
56
Higher index of clinical suspicion, prompt intervention, and appropriate antimicro-
bial therapy improves prognosis.
MYOCARDITIS
Introduction
Myocarditis is the inflammation of myocardium due to infectious and noninfectious
causes. It has variable clinical presentations mimicking other cardiac emergencies.
Presence of an inflammatory cellular infiltrate with or without associated myocyte
necrosis on stained heart-tissue sections defines myocarditis based on the Dallas
criteria. Fulminant lymphocytic myocarditis associated with preceding viral prodromal
symptoms within a couple of weeks has good prognosis. On the other hand, acute
lymphocytic (nonfulminant) myocarditis has more gradual onset of cardiovascular
symptoms and is associated with poor prognosis.
64
Causes
Infectious agents as well as drugs, toxins, and autoimmune disorders, including
sarcoidosis, can cause myocarditis.
Viral infections are the most common cause of acute myocarditis, coxsackievirus B
has been the most reported. Other viral causes include the influenza virus, cytomeg-
alovirus, hepatitis C virus, and adenovirus and parvovirus B19.
6467
A large European prospective placebo-controlled multicenter study involving more
than 3055 subjects showed viral cause in 11.8% of acute or chronic myocarditis
subjects with reduced ejection fraction. The viruses included enterovirus 2.2%, cyto-
megalovirus 5.4%, and adenovirus 4.2%.
67
Influenza virus infection is known to cause myocarditis in complicated cases, but
the exact prevalence is not known. A pregnant patient was diagnosed with perimyo-
carditis during acute H1N1 influenza illness and fulminant myocarditis with a fatal
outcome was reported in a pediatric patient during the 2009 H1N1 pandemic.
68
Cardiac Emergencies 1163
Myocarditis can develop as a side effect of vaccination. Two reported cases of
myocarditis following small pox immunization have been reported.
69
Acute myopericarditis caused by dual infection with coxsackieviruses A and B has
been reported.
70
The most common virus detected was in myocarditis in a German study was parvo-
virus B19 followed by human herpes virus 6 (HHV-6) and both parvovirus B19 and
HHV-6. Coxsackievirus B and Epstein- Barr virus were detected in one subject each.
Most subjects presented with chest pain followed by cardiac failure and malaise.
Interestingly, subjects with parvovirus B19 had better outcomes even though intermit-
tent myocardial infarct-like illness was common in first 4 weeks of illness. Patients with
HHV-6 had worse prognoses and most subjects with dual infection with
parvovirus B19 and HHV-6 did not improve at all. Dual infection and HHV-6 myocar-
ditis tend to present with new onset heart failure and septal late gadolinium enhance-
ment on cardiac MRI, and to develop chronic heart failure.
66
Case reports of bacterial myocarditis include those caused by Staphylococci spp,
Streptococci spp, and Borrelia burgdoferi.
7174
Acute Lyme disease myocarditis has
been present with atrioventricular block.
74
Clinical Presentation
Clinical presentation of myocarditis includes acute or subacute onset of idiopathic
cardiac failure following a viral-like illness or upper-respiratory infection, mild chest
pain, respiratory distress, cardiogenic shock, malignant cardiac arrhythmia, and
sudden death. Most commonly, it presents as cardiac failure with nonischemic dilated
cardiomyopathy of acute or subacute onset. Preceding viral illness may or may not be
present.
64
Myocarditis can present as myopericarditis. In a study of acute pericarditis, myo-
pericarditis was found in 14.6% of the subjects. Independently associated clinical
features included arrhythmia and ST-segment elevation, male gender, age less than
40 years, and recent febrile illness.
75
A recent case series found a distinct subset of young males (age 1742) presenting
with acute chest pain, ST-segment elevation, and elevated cardiac enzymes. This
condition was preceded by viral-like illness except in one subject. This was not
followed by development of Qwave and cardiac angiogram was normal. The outcome
was favorable.
76
Diagnosis
Endomyocardial biopsy is the gold standard for diagnosis of myocarditis but is not
routinely performed. Recent studies suggest that noninvasive imaging such as cardiac
MRI can be used to diagnose acute myocarditis, which shows as an abnormal signal in
the affected area.
64
Abnormal EKG findings are common in patients with myocarditis. In a German
study, 77% of subject with biopsy proven myocarditis had abnormal EKG finding at
presentation. The most common abnormal EKG finding was ST-segment abnormali-
ties (69%), followed by bundle branch block (26%), and Q wave (8%); however,
a normal EKG does not rule out myocarditis.
77
Management
Management of acute myocarditis is supportive care for left ventricular dysfunction
and arrhythmia control.
64,65
The use of glucocorticoids in acute phase of myocarditis
is not recommended owing to harmful effects shown in animal models with
Htwe & Khardori 1164
coxsackievirus infection and lack of benefit in controlled trials. Cyclosporine for immu-
nosuppressive therapy offered marginal benefit.
78,79
Data from animal studies has shown beneficial effect of IV immunoglobulin.
However, a placebo-controlled trial in humans did not show any benefit and IV immu-
noglobulin therapy is not routinely recommended in adults.
64,65
Use of antivirals in myocarditis is controversial. The beneficial effect of interferon
has been demonstrated in animal models, but controlled human studies did not
support its use. Myocarditis usually presents a fewweeks after the initial viral infection,
but studies have shown that persistent presence of viral genome in myocardium is
associated with poor outcome. A study showed a decrease or clearance of persistent
viral genome in myocardium with interferon therapy in chronic myocarditis. The
viruses treated were enterovirus, parvovirus B19, and adenovirus. Specific antiviral
therapy with ganciclovir improved the outcome in cytomegalovirus myocarditis. If
a bacterial pathogen is revealed or suspected, antibacterial therapy should be
instituted.
64,65
SUMMARY
Cardiac infections presenting as emergencies include complications of infective endo-
carditis, including congestive heart failure, chordae tendinae rupture, cardiac arrhyth-
mias, and embolic phenomenon; acute pericarditis, including cardiac tamponade; and
acute myocarditis presenting with malignant cardiac arrhythmias or congestive heart
failure. Most of these emergent infectious disease manifestations of the cardiovas-
cular system have a good prognosis if diagnosed early and managed appropriately.
Newer diagnostic modalities and combined treatment guidelines are available from
the European Society of Cardiology and the American Heart Association.
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