Infective Endocarditis in Patients Addicted to Injected Opioid Drugs

Michael J Javorski; Brad F Rosinski; Shawn Shah; Matthew A Thompson; David Streem; Steven M Gordon; Steven Insler; Penny L Houghtaling; Brian Griffin; Eugene H Blackstone; Shinya Unai; Lars G Svensson; Gösta B Pettersson; Haytham Elgharably

doi:10.1016/j.jacc.2023.12.016

Infective Endocarditis in Patients Addicted to Injected Opioid Drugs

J Am Coll Cardiol. 2024 Feb 27;83(8):811-823. doi: 10.1016/j.jacc.2023.12.016.

Affiliations

¹ Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA.
² Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA.
³ Department of Psychiatry, Cleveland Clinic, Cleveland, Ohio, USA.
⁴ Department of Infectious Disease, Cleveland Clinic, Cleveland, Ohio, USA.
⁵ Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, Ohio, USA.
⁶ Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA.
⁷ Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA.
⁸ Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA.
⁹ Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA. Electronic address: Elgharh@ccf.org.

PMID: 38383096
DOI: 10.1016/j.jacc.2023.12.016

Abstract

Background: Persons who inject drugs and require surgery for infective endocarditis have 2 potentially lethal diseases. Current postoperative rehabilitation efforts seem ineffective in preventing loss to follow-up, injection drug use relapse (relapse), and death.

Objectives: The purpose of this study was to characterize drug use, psychosocial issues, surgical outcome, and postoperative addiction management, as well as loss to follow-up, relapse, and mortality and their risk factors.

Methods: From January 2010 to June 2020, 227 persons who inject drugs, age 36 ± 9.9 years, underwent surgery for infective endocarditis at a quaternary hospital having special interest in developing addiction management programs. Postsurgery loss to follow-up, relapse, and death were assessed as competing risks and risk factors identified parametrically and by machine learning. CIs are 68% (±1 SE).

Results: Heroin was the most self-reported drug injected (n = 183 [81%]). Psychosocial issues included homelessness (n = 56 [25%]), justice system involvement (n = 150 [66%]), depression (n = 118 [52%]), anxiety (n = 104 [46%]), and post-traumatic stress disorder (n = 33 [15%]). Four (1.8%) died in-hospital. Medication for opioid use disorder prescribed at discharge increased from 0% in 2010 to 100% in 2020. At 1 and 5 years, conditional probabilities of loss to follow-up were 16% (68% CI: 13%-22%) and 59% (68% CI: 44%-65%), relapse 32% (68% CI: 28%-34%) and 79% (68% CI: 74%-83%), and mortality 21% (68% CI: 18%-23%) and 68% (68% CI: 62%-72%). Younger age, heroin use, and lower education level were predictors of relapse.

Conclusions: Infective endocarditis surgery can be performed with low mortality in persons who inject drugs, but addiction is far more lethal. Risk of loss to follow-up and relapse require more effective addiction strategies without which this major loss to society will continue.

Keywords: cardiac surgery; competing risks; injection drug use; intravenous drug use; relapse.

MeSH terms

Adult
Analgesics, Opioid
Drug Users*
Endocarditis* / epidemiology
Endocarditis* / etiology
Endocarditis, Bacterial* / complications
Endocarditis, Bacterial* / etiology
Heroin
Humans
Middle Aged
Recurrence
Retrospective Studies
Substance Abuse, Intravenous* / complications
Substance Abuse, Intravenous* / epidemiology

Substances

Analgesics, Opioid
Heroin