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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 February 2, 2021 e161 CLINICAL STATEMENTS AND GUIDELINES

resulting in ischemia, often followed by hemorrhagic transformation. Anticoagulant therapy may increase the risk of an embolic infarct converting to a hemorrhagic infarct, and this risk must be weighed against the higher risk of recurrent embolization and valve dysfunction, particularly in patients on anticoagulation for a prosthetic valve. A specialist in the field of neurology or neuroradiology should be added to the Heart Valve Team when stroke complicates IE.11,18–24 4.	 POET randomized stable patients who had leftsided endocarditis caused by streptococcus, E. faecalis, S. aureus, or coagulase-negative staphylococci to treatment arms of continued intravenous treatment or a switch to oral antibiotic treatment after antibiotics had been administered intravenously for at least 10 days. Within 1 to 3 days before the completion of the assigned antibiotic treatment, TEE was performed to confirm that the patient had a sufficient response to treatment as part of this protocol.25 5.	 In patients with native valve endocarditis, routine use of VKA is not recommended. In patients on VKA for other indications who have IE, VKA discontinuation should be considered at the initial presentation for several reasons: 1) the risk of bleeding associated with any needed urgent invasive procedures, 2) the risk of hemorrhagic stroke, and 3) the possible need for early surgery, which is required in roughly 50% of patients with prosthetic valve endocarditis. There are no RCTs studying the use of bridging therapy with intravenous or subcutaneous anticoagulant therapy in patients with IE, but observational studies suggest an increased risk of hemorrhagic stroke in patients on intravenous UFH during the acute phase of acute IE. Decisions about continued anticoagulation and antiplatelet therapy should ultimately be directed by the patient’s cardiologist and cardiothoracic surgeon, in consultation with a neurology specialist if neurological findings are clinically present or noted on imaging.11,27–34

6.	 Two sets of blood culture samples are the minimum for a secure microbiological diagnosis of IE.

Figure 15. Diagnosis of IE. Colors correspond to Table 2. CT indicates computed tomography; IE, infective endocarditis; 18FDG, 18F-fluorodeoxyglucose; NVE, native valve endocarditis; PET, positron emission tomography; PVE, prosthetic valve endocarditis; TEE, transesophageal echocardiography; and TTE, transthoracic echocardiography.

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