Infective Endocarditis in Opioid Users: Care Must Go Beyond the Heart

For people who require surgery to treat infective endocarditis (IE) on the backdrop of injected drug use, the addiction is far more lethal than the surgery itself and merits close attention, according to a newly published report from the Cleveland Clinic that shows just how hard it is to overcome the challenges of relapse and loss to follow-up.

Still, senior author Haytham Elgharably, MD (Cleveland Clinic, OH), stressed to TCTMD that a comprehensive approach is key. “We look at this at the Cleveland Clinic as a two-disease problem. . . . You cannot just treat the endocarditis and not really address the addiction problem,” he said.

Elgharably acknowledged there’s ongoing debate about how best to deal with people who continue injecting drugs—typically opioids—after their first surgery for IE, only to return with the same condition. In these cases, it’s “draining clinically, financially, and ethically for the whole medical team caring for these patients,” he said. “When the patient comes back within a few months, obviously it’s frustrating.”

He emphasized the scope of the opioid epidemic and its impact on society: “It’s as bad as COVID. . . . They are all young people who should have life ahead of them. They should have families, careers.”

The study tracks the Cleveland Clinic’s experience over the decade between 2010 and 2020, during which their approaches to this scenario evolved. This work, he said, involved “multiple efforts from many, many people.”

Nowadays, with a more-formal program in place, “you do the surgery and try to help the patients: you hook them up with good postop rehab, you get the psych team to see them before. But occasionally we still see patients come back with relapse,” said Elgharably, or worse: get word that someone has died from an overdose.

He said the idea with this paper, published recently in the Journal of the American College of Cardiology, was to look at what outcomes are being achieved and whether it would help to try different tactics.

Their study didn’t show noticeable improvements—yet. It may be that there simply “was not enough time to see an impact. . . . At the same time, we also don’t want to underestimate the long-term results that we have so far,” said Elgharably, adding that they intend to keep up their efforts and continue tracking any progress.

Speaking with TCTMD, Bernard Prendergast, MD (Cleveland Clinic London, England), said that when it comes to IE treatment, the question of how to address addiction doesn’t get much attention in the cardiovascular literature. “A lot of our focus is around the imaging and the intervention and the surgery and the immediate outcomes, but this paper takes our thinking into a whole area of novelty: the long-term follow-up of these patients and how they’re cared for beyond their heart care,” he said, agreeing with the authors that there are two diseases at play.

The Cleveland Clinic experience in Ohio is large, “but sadly it’s not a unique experience,” said Prendergast. In London, where he practices, the “proportion of patients with addiction-related endocarditis is steadily increasing all the time.”

What is clear, Prendergast stressed, is that a team approach is required. “To be blunt, I think the surgeon is the least important person here, and that’s demonstrated by the data,” he pointed out. The mortality rates achieved at the Cleveland Clinic and other skilled centers are “exceedingly low for cardiac surgery and endocarditis. In a sense, the worry is not the operation, the worry is the adverse long-term consequences.”

Management should take the perspective of prevention, not just treatment of events that have occurred, he said. The new data “are important because they highlight the issue and present the challenges in a very clear, statistical basis.” The problem will never completely be eradicated, added Prendergast, but “dealing with individual patients and offering them a tailored package is the way forward.”

Seven in 10 Die by 5 Years

Led by Michael J. Javorski, MD (Cleveland Clinic), the analysis included 227 users of injection drugs (mean age 36 years; 43% female), most often heroin, who underwent surgery for IE at the Cleveland Clinic between January 2010 and June 2020. Surgeries involved the aortic valve in 48% of patients, mitral in 44%, tricuspid in 55%, and pulmonary in 1.8%. The IE affected left-sided valves in 44%, right-sided in 30%, and both in 26%. Fully 30% of the surgeries were reoperations.

Most of the patients (81%) reported using heroin when their IE occurred, with 26% using cocaine, and 15% using methamphetamines. A quarter were unhoused, two-thirds had justice system involvement (arrest, incarceration, or driving under the influence of alcohol), 52% had depression, 46% anxiety, and 15% posttraumatic stress disorder. For 63%, graduating from high school was their highest level of education, and 25% had dropped out of high school.

[It’s] draining clinically, financially, and ethically for the whole medical team caring for these patients. Haytham Elgharably

In-hospital mortality was 1.8%. Median length of stay was 12 days. Two-thirds were discharged to a skilled nursing or other medical facility, of whom just 11% went somewhere with access to intensive outpatient addiction therapy. Eight patients (3.6%) left against medical advice. By 2020, 100% of patients were discharged on medication for opioid use disorder (MOUD), as compared with none in 2010.

Patients’ trajectories after discharge were murky. Because the researchers thought loss to follow-up could lead to relapse and death being underestimated, they calculated these outcomes as competing risks. By 1 year, they estimated 16% had been lost to follow-up, 32% had relapsed, and 21% had died. By 5 years, fully 59% were lost to follow-up, 79% had relapsed, and 68% had died.

Importantly, risk of relapse peaked at 9 months.

People with diagnoses of anxiety or mood disorders were less likely to be lost to follow-up, and predictors of relapse included younger age, heroin use, and education level below high school graduate.

“Despite our evolving addiction treatment and surveillance strategies over the decade, our analyses indicate that injection drug use continues unabated,” Javorski and colleagues conclude. “Thus, of the two lethal diseases—opioid addiction and infective endocarditis—we sadly report that opioid addiction was more lethal than advanced infective endocarditis treated with surgery.”

What Can Be Done

As to what could make a dent in relapse and mortality, the investigators draw attention to the first year after surgery. “Specifically, during that time, our data suggest that these patients should be offered rehabilitation, medication assistance, psychiatric counseling, medication for mood or anxiety disorders, homelife assessment to ensure a safe home environment and family support, and close follow-up with a member of the endocarditis team,” they suggest.

Prendergast, for his part, said the initial “admission for infection needs to be an immediate stimulus for a much wider package of care,” but he also outlined many obstacles. “Managing the behavior and the medical aspects of addiction is extremely challenging. These patients often don’t engage in healthcare. They are itinerant: they move from place to place, from institution to institution. And there are many societal and environmental factors that impact on their behavior. This is way beyond the constraints of the operating room or the outpatient clinic,” he said, adding that patients often abscond right after their surgery and, for a variety of reasons, don’t return that particular clinic.

Elgharably said better follow-up after discharge, when patients may be on IV antibiotics and in cardiac rehab, “is an opportunity to intervene and really ensure that these patients stay sober through at least the first 6 months to a year.” To do this, they’re starting to partner with rehab facilities that can address addiction.

Another option is the “bridge to surgery,” where patients with right-sided IE whose surgery can be delayed safely are given a chance to address their addiction prior to treatment.

It’s also valuable to understand, for the successful cases, which factors are helping them stay sober. “Usually there is a family member, like a mother or a spouse, that’s putting in a lot of effort to help or support the patient,” said Elgharably. Or the patient, if they have children, may be worried about losing custody.

But no matter what strategies clinicians and hospitals employ, they can only do so much, he added. Statewide or regional programs are needed for higher-level support in this effort, especially for patients who don’t live locally.

Krish C. Dewan, MD, and Carmelo A. Milano, MD (both from Duke University Medical Center, Durham, NC), in accompanying editorial, describe the data as “sobering.”

“Should the lack of any measurable survival or relapse benefit discourage others from attempting large-scale multidisciplinary efforts? No—the truth of the matter is that it may be too early to decipher the true effect of the organized addiction management program described,” they say.

The editorialists similarly point out that the dual problem of IE and addiction needs to be addressed at multiple levels.

“Practitioners may engage patients at the individual level by increased screening, patient-centered discussions on common goals before surgery, and early engagement of addiction medicine and associated care teams. At the institutional level, coordination between inpatient and outpatient care teams is necessary to ensure that patients are not just bridged to their next phase (eg, an addiction/rehabilitation program) but also have the means to reasonably continue to be engaged with the pathway,” they note, adding that centers of excellence and local community programs might, through collaboration, mitigate loss to follow-up. And finally, they add, individual clinicians and the broader medical community can use their clout to promote interventions targeting social determinants of health.

For now, though, there is “no silver bullet in caring for this patient population,” Dewan and Milano concur.

The Cleveland Clinic Experience

Over the decade described, the Cleveland Clinic’s approach changed considerably. Initially, patients with IE who injected drugs were encouraged to agree to addiction treatment, either verbally or by signing a nonbinding contract. There was little enthusiasm for discharging these patients on MOUD and in-hospital psychiatric evaluation wasn’t standardized.

“But in 2015, driven by nursing, a specialized multidisciplinary addiction team began developing a program called MOSAIC (Management of Substance Abuse Disorder and Heart Infections in Cardiovascular Patients) that included standardized protocols for preoperative, perioperative, and postoperative care,” the paper notes.

Then in 2017, they established an Endocarditis Center, also with a team approach to IE in injection drug users, who underwent “preoperative evaluation by a psychiatric addiction specialist along with a cardiologist, infectious disease specialist, and cardiac surgeon.” That same year Cleveland Clinic’s psychiatrists received privileges to see patients at a local rehab center, and in 2019, Ohio launched Project SOAR, a program aimed at promoting recovery from opioid addiction. Cleveland Clinic’s MOSAIC program was fully deployed in 2020.