Antithrombotic therapy in patients with infective endocarditis
- Thomas L Ortel, MD, PhD
Thomas L Ortel, MD, PhD
- Professor of Medicine & Pathology
- Hemostasis & Thrombosis Center, Duke University
- William H Gaasch, MD
William H Gaasch, MD
- Section Editor — Valvular Disease
- Professor of Medicine
- University of Massachusetts Medical School
- Tufts University School of Medicine
- Senior Consultant in Cardiology
- Lahey Clinic
- Section Editors
- Lawrence LK Leung, MD
Lawrence LK Leung, MD
- Editor-in-Chief — Hematology
- Section Editor — Disorders of Hemostasis and Coagulation
- Professor of Medicine
- Stanford University School of Medicine
- Daniel J Sexton, MD
Daniel J Sexton, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine
- Duke University Medical Center
Management of antithrombotic therapy (anticoagulant and antiplatelet agents) in patients with infective endocarditis (IE) is challenging given the competing risks of embolism and intracerebral hemorrhage in this condition and limited evidence on the effects of therapy. Anticoagulant and antiplatelet therapy have not been shown to reduce the risk of embolism in IE. However, many patients with IE have indications for antithrombotic therapy, particularly patients with mechanical prosthetic valves. In such patients, the potential risks and benefits of antithrombotic therapy must be carefully weighed.
The use of anticoagulants and antiplatelet agents in patients with IE will be reviewed here. The treatment and complications of IE are presented separately.
- Whitlock RP, Sun JC, Fremes SE, et al. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e576S.
- Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2015; 132:1435.
- Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015; 36:3075.
- Habib G, Hoen B, Tornos P, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J 2009; 30:2369.
- Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523.
- Linkins LA, Dans AL, Moores LK, et al. Treatment and prevention of heparin-induced thrombocytopenia: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e495S.
- Scott WR, New PF, Davis KR, Schnur JA. Computerized axial tomography of intracerebral and intraventricular hemorrhage. Radiology 1974; 112:73.
- Asaithambi G, Adil MM, Qureshi AI. Thrombolysis for ischemic stroke associated with infective endocarditis: results from the nationwide inpatient sample. Stroke 2013; 44:2917.
- Ong E, Mechtouff L, Bernard E, et al. Thrombolysis for stroke caused by infective endocarditis: an illustrative case and review of the literature. J Neurol 2013; 260:1339.
- Rasmussen RV. Anticoagulation in patients with stroke with infective endocarditis is safe. Stroke 2011; 42:1795.
- Dickerman SA, Abrutyn E, Barsic B, et al. The relationship between the initiation of antimicrobial therapy and the incidence of stroke in infective endocarditis: an analysis from the ICE Prospective Cohort Study (ICE-PCS). Am Heart J 2007; 154:1086.
- García-Cabrera E, Fernández-Hidalgo N, Almirante B, et al. Neurological complications of infective endocarditis: risk factors, outcome, and impact of cardiac surgery: a multicenter observational study. Circulation 2013; 127:2272.
- Barsic B, Dickerman S, Krajinovic V, et al. Influence of the timing of cardiac surgery on the outcome of patients with infective endocarditis and stroke. Clin Infect Dis 2013; 56:209.
- Anavekar NS, Tleyjeh IM, Anavekar NS, et al. Impact of prior antiplatelet therapy on risk of embolism in infective endocarditis. Clin Infect Dis 2007; 44:1180.
- Anavekar NS, Schultz JC, De Sa DD, et al. Modifiers of symptomatic embolic risk in infective endocarditis. Mayo Clin Proc 2011; 86:1068.
- Chan KL, Dumesnil JG, Cujec B, et al. A randomized trial of aspirin on the risk of embolic events in patients with infective endocarditis. J Am Coll Cardiol 2003; 42:775.
- Tornos P, Almirante B, Mirabet S, et al. Infective endocarditis due to Staphylococcus aureus: deleterious effect of anticoagulant therapy. Arch Intern Med 1999; 159:473.
- Rasmussen RV, Snygg-Martin U, Olaison L, et al. Major cerebral events in Staphylococcus aureus infective endocarditis: is anticoagulant therapy safe? Cardiology 2009; 114:284.
- Snygg-Martin U, Rasmussen RV, Hassager C, et al. Warfarin therapy and incidence of cerebrovascular complications in left-sided native valve endocarditis. Eur J Clin Microbiol Infect Dis 2011; 30:151.
- MANAGEMENT APPROACH
- Clinical settings
- - Patients without other indications for antithrombotic therapy
- - Patients with other indications for antithrombotic therapy
- Conditions commonly treated with anticoagulants
- - Prosthetic valves
- - Atrial fibrillation
- - Venous thromboembolism
- Conditions commonly treated with antiplatelet therapy
- - Coronary heart disease
- - Secondary prevention of ischemic stroke
- - Primary prevention of cardiovascular disease and cancer
- Management of antithrombotic therapy if continued
- Management of cerebral complications
- - Ischemic stroke
- - Intracerebral hemorrhage
- Role of valve surgery
- Risk of embolism in IE
- - Estimates of risk
- - Risk factors
- Risk of intracerebral hemorrhage
- Effect of antithrombotic therapy
- - Antiplatelet therapy
- - Anticoagulant therapy
- SUMMARY AND RECOMMENDATIONS