NeuroFarBa Department, University of Florence, Florence, Italy.
Department of Safety and Bioethics, Catholic University School of Medicine, Rome, Italy.
Cardiology. 2024;149(5):513-522. doi: 10.1159/000538549. Epub 2024 Apr 4.
Incidence of infective endocarditis (IE) is progressively raising because of the increasing number of cardiovascular invasive procedures, support treatment and devices, awareness in the medical community, and improved diagnostic modalities. IE pathophysiology is a unique model of immunothrombosis, and the clinical course is often complicated by either embolic or hemorrhagic events. Managing antithrombotic treatment is challenging and the level of supporting evidence scant. The aim of this review was to discuss and present the embolic and bleeding complication associated with IE and review the available evidence on antithrombotic treatment in patients with IE with and without a previous indication to antithrombotic drugs.
Embolic events occur in 20-40% of patients with IE and are associated with high morbidity and mortality. Acute ischemic stroke is the most common neurological complication. A beneficial effect of antithrombotic therapy in preventing ischemic stroke for patients with IE has never been formally tested in adequately powered randomized clinical trials. Atrial fibrillation is a common complication associated with severe infections, requiring anticoagulation. Furthermore, patients with IE have a high risk of unprovoked and anticoagulation treatment-related bleeding. In particular, intracerebral bleeding is the most severe complication in about 5% of patients with IE. Single antiplatelet therapy with low-dose aspirin after hospitalization for IE has been shown to reduce causes mortality within 90 days without an increase of hemorrhagic strokes. In the absence of bleeding complications, recent guidelines recommend to maintain low-dose aspirin. No data are available on the management of patients with IE while on dual antiplatelet therapy.
Several gaps in knowledge remain about antithrombotic management in patients with IE and most of the evidence relies on observational studies. Individualized strategies based on clinical evaluation, comorbidities, patient engagement, and shared decisions strategies are encouraged.
由于心血管介入治疗、支持治疗和装置的增加、医学界对该病的认识提高以及诊断方法的改进，感染性心内膜炎（IE）的发病率逐渐上升。IE 的病理生理学是一种独特的免疫血栓形成模式，其临床病程常伴有栓塞或出血事件。抗血栓治疗管理具有挑战性，支持证据水平较低。本综述的目的是讨论和介绍与 IE 相关的栓塞和出血并发症，并回顾现有证据，以了解 IE 患者（包括有和无先前抗血栓药物指征的患者）的抗血栓治疗。
IE 患者中有 20-40%发生栓塞事件，与高发病率和死亡率相关。急性缺血性脑卒中是最常见的神经系统并发症。抗血栓治疗预防 IE 患者缺血性脑卒中的有益效果从未在充分的随机临床试验中得到正式检验。房颤是一种与严重感染相关的常见并发症，需要抗凝治疗。此外，IE 患者有较高的非自发性和抗凝治疗相关出血风险。特别是颅内出血是约 5%IE 患者最严重的并发症。IE 住院后使用低剂量阿司匹林进行单一抗血小板治疗已被证明可降低 90 天内的死亡率，而不会增加出血性中风。在没有出血并发症的情况下，最近的指南建议维持低剂量阿司匹林。目前尚无关于 IE 患者同时进行双联抗血小板治疗的管理数据。
IE 患者抗血栓治疗管理方面仍存在一些知识空白，大部分证据依赖于观察性研究。鼓励根据临床评估、合并症、患者参与度和共同决策策略制定个体化策略。
