Opioid Epidemic Brings Higher Rates of Endocarditis, Stroke

HONOLULU, HI—The opioid epidemic that has been raging for more than a decade in North America has ushered in rising rates of infective endocarditis (IE) and stroke, new US data show.

The rate of stroke hospitalizations related to IE and opioid abuse remained relatively stable between 1993 and 2008, but after that point—coinciding with an intensification of the opioid problem—such admissions spiked, Setareh Salehi Omran, MD (Weill Cornell Medicine, New York, NY), reported here at the International Stroke Conference.

The analysis, published simultaneously online in Stroke, indicates that the most substantial increases occurred in young people, women, and non-Hispanic whites from the northeastern and southern parts of the country.

To TCTMD, Salehi Omran said these findings could be used to inform discussions between physicians and their patients with a history of IV opioid use, adding to the known risks of cardiac complications and mortality.

“Once you tell people that they’re at an increased risk of stroke, I think a lot of people can relate to that in some way because they either know someone who had a stroke or have seen advertisements about how to prevent a stroke from happening,” she said. “It adds another layer to the whole concept of what are the complications associated with it. As clinicians, we can counsel our patients that you may end up having a stroke and that can cause you to not be able to do everything you were able to do before. You might become very functionally impaired because of it.”

On a broader scale, Salehi Omran added, these findings could raise public awareness of the cardiovascular complications of IV opioid use and help with future initiatives to address it.

Commenting for TCTMD, Brian Silver, MD (UMassMemorial Medical Center, Worcester, MA), said the study “reinforces the dangers of opioid agents in general and in particular it highlights another potential hazard associated with the use of opioids—namely, that it can cause seeding of the heart valves with bacteria, which can [embolize and] then lodge in the brain and cause strokes. So besides dying from a respiratory arrest you can also suffer a significant stroke, leading to another potential cause of death.”

Clumps of Bacteria Embolize to the Brain

The surge in IV opioid use over the past decade has been well documented. IE is a known complication of IV drug use, and this has been increasing as well, especially in young people. In about 20% of IE cases, clumps of bacteria embolize to the brain, causing ischemic and hemorrhagic strokes, but little is known about how often this occurs in relation to opioid-associated IE and about recent trends.

To explore the issue, Salehi Omran and colleagues examined data from the National Inpatient Sample. Out of more than 14.4 million hospitalizations for stroke between 1993 and 2015, the researchers identified 5,283 related to IE and opioid abuse. As they had hypothesized, the rate of such admissions increased over the study period—from 2.4 to 18.8 per 10 million US residents. There was a noticeable jump, however, after the opioid epidemic began to worsen around 2008, with an annual increase of 20.3% in the latter part of the time span.

“These novel findings indicate that increasing opioid abuse in the United States is not only causing more social/occupational dysfunction, cardiac complications, and premature mortality but may also be increasing the population burden of permanent functional disability as a result of stroke,” Salehi Omran et al write.

This trend could be related to greater IV heroin use, which “can cause IE through various mechanisms, including the introduction of bacteria into the bloodstream from dirty needles or contaminated syringes, endothelial damage on valves from repetitive drug use, and use of saliva as a diluting agent or as lubrication on injection needles,” they say. “The rise in heroin use combined with these high-risk injection practices may explain why opioid-related IE is becoming more prevalent and leading to complications, such as stroke and death.”

Silver said that he’s not surprised by the findings because of what he’s observed firsthand in the area where he works.

“We’ve seen an increase in the occurrence of endocarditis and stroke associated with it,” Silver said. “We’d always speculated it had something to do with the use of needles and opioid agents, and this study just confirms that this is a trend nationally, particularly in the northeast and the southeast parts of the United States.”

This is worrying because of the disproportionate effect on younger people and the high risk of mortality associated with such cases, Silver said. “Stroke without endocarditis carries a high mortality rate, but in particular endocarditis-associated stroke has an even higher mortality rate. . . . Because of the risk of developing microaneurysms related to the endocarditis, people can hemorrhage and then bleed into their brain and die. So, even though it’s not a frequent event relative to all strokes that we see, it can be lethal and therefore it is a public health concern, at least from the stroke neurology standpoint.”

Silver added that efforts to tackle the larger problem of opioid abuse are likely to pay dividends in terms of stroke. “All the measures that are being taken right now from a public health policy perspective are directed at trying to reduce the occurrence of death related to opioids,” he said, “but if we can reduce use of opioid agents, likely we will start seeing declines in endocarditis and endocarditis-related stroke.”