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Revised guidelines target endocarditis prophylaxis
The revisions center on recommended prophylactic treatment for infective endocarditis.
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A joint task force of the American College of Cardiology and the American Heart Association has released a focused update of the valvular heart disease guidelines.
After reviewing results from recent clinical trials and other literature, the writing committee decided that major revisions to the section containing recommendations for endocarditis prophylaxis were warranted. Specifically, the committee addressed long-standing recommendations for the appropriateness of antimicrobial prophylaxis for infective endocarditis prior to specific dental, gastrointestinal and genitourinary procedures.
Updated recommendations
After reviewing the data, the committee determined that only a small number of cases of infective endocarditis may be prevented by antibiotic prophylaxis. It is reasonable to use antibiotic prophylaxis “only in patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis,” the task force decided. In those patients, the committee found it reasonable to use antibiotic prophylaxis “in all dental procedures involving manipulation of gingival tissue or the periapical region of teeth or perforation of oral mucosa.” They also recommended that prophylaxis not be used “solely to prevent endocarditis” in patients undergoing gastrointestinal or genitourinary procedures, or that it be used exclusively on the basis of lifetime risk of acquisition of infective endocarditis.
The 2008 focused revisions break with long-time recommendations, some of which had been in place since 1955. The change, according to the writing group, was necessary.
“These changes are a significant departure from the past AHA and European Society of Cardiology recommendations for prevention of infective endocarditis and may violate long-standing expectations in practice patterns of patients and health care providers,” the committee wrote in the report. “All data were reviewed thoroughly and the current recommendations reflect analysis of all relevant literature.” – by Eric Raible
For more information:
- Nishimura RA, Carabello BA, Faxon DP, et al. ACC/AHA 2008 guideline update on valvular heart disease: Focused update on infective endocarditis. Circulation. 2008;doi:10.1161/CIRCULATIONAHA.108.190377.
There has been 50 years of assumption for infective endocarditis prophylaxis that there really was no data for, and it was important that they revised the endocarditis prophylaxis guidelines overall. It was long overdue. I see it having a huge effect on practice. We used to cover all of these patients, and the percentage that we now need to cover has dropped by a high number. Most cardiologists have accepted the revisions. The dentists have moved to accept them, but the adult congenital group has been concerned. The Adult Congenital Heart Disease Guidelines should be out in a few months, and the group struggled hard with it. The ACC/AHA writing committee left prophylaxis as a Class IIb indication, so they left it open for the practitioners if they are uncomfortable not covering their patients. The reality is that the evidence that prophylaxis works is small and the evidence that just covering a dental procedure is going to protect a patient is incorrect.
– Thomas Bashore, MD
Cardiology Today Editorial Board member