University of Alabama at Birmingham School of Medicine
Infectious Endocarditis in Elders
· Prevalence of Infective endocarditis in elderly has been increasing with mean age now being 55 to 60 years; this increase is attributed to aging with associated calcification of valves and increasing number of elderly patients with prosthetic valves.
· The common organisms causing IE in elderly are S.aureus, Group D streptococci, and Enterococci and they most frequently arise from gastrointestinal or genitourinary source unlike in young adults where the most common source is oropharynx. S.epidermidis is the frequent cause of native valve endocarditis.
· The diagnosis of IE is difficult in elderly because fever and leukocytosis are less common than in young adults. Positive blood cultures occur with equal frequency.
· Ability to diagnose IE with Trans thoracic echo is limited due to presence of calcified valves and presence of co-morbidities like obesity and obstructive lung disease. Elderly patients more often have small vegetations or prosthetic valve infection. Trans esophageal echo offers improved image quality and should be strongly considered when endocarditis is suspected.
· Antibiotic treatment of IE is similar to that in young adults – directed at the identified pathogen and administered IV for 2-6wks.
· Studies suggest although predisposing heart disease and causative organisms are different between the elderly and middle-aged patients, the incidence of major complications is similar. Also sometimes there is lower incidence of embolic events.
· Early surgical intervention compared with medical therapy alone is associated with increased short and long term survival rates, primarily when IE is caused by S.aureus. Despite higher operative risk in elderly surgical intervention should be considered early in elderly.
· The most effective therapy for endocarditis in elderly is prevention by use of antibiotic prophylaxis per American Heart Association guidelines.
· The more insidious clinical course in elderly leads to the delay in diagnosis until after the irreversible complications has occurred causing more severe prognosis.
References:
1.J.Cardiology clinics vol.17,no.1,Feb.19999
2.Textbook of Principles of Geritrics,Hazzard
Supported by a grant from the Association of American Medical Colleges and the John A. Hartford Foundation.