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Endocarditis is always bad news. Standard lines of defence include rapid diagnosis, rapid initiation of antibiotic therapy and meticulous vigilance regarding complications. Despite advances in each of these areas, the terrible morbidity of this disease persists. Among our patients with endocarditis, are there those about whom we should worry even more, ones for whom we need to push ourselves, our health systems and colleagues even harder than usual? The answer may be yes.
There is a growing literature that supports early cardiac surgery to improve patient outcomes in high-risk patients with left-sided valve infections.1 2 Factors such as uncontrolled sepsis, paravalvular extension of infection, heart failure and recurrent embolisation have been identified by different groups as predictors of poor outcome during initial hospitalisation or in the first 6 months following discharge. These factors may identify those for whom an aggressive and accelerated treatment plan is appropriate. If a patient is likely to have a complicated course with endocarditis, the benefit of moving to early surgery will be greatest during the earliest days after diagnosis, as the embolic risk falls rapidly over the first 2 weeks of antibiotic therapy.3 High-risk patients should therefore be identified as early in their course as possible, so that if surgery is likely to avoid additional morbidity or mortality, it can be organised expeditiously.
In their paper published in this issue of Heart, Dr Javier López and colleagues4 from four tertiary referral hospitals in Spain …