Is hypertension associated with infective endocarditis?

Hypertension in Infective Endocarditis

High blood pressure is not a typical feature of infective endocarditis (IE); rather, heart failure with hypotension and cardiogenic shock are more common cardiovascular complications. According to the European Society of Cardiology (ESC) guidelines, heart failure is the most frequent complication of IE, occurring in 42-60% of native valve endocarditis cases 1.

Cardiovascular Manifestations in Infective Endocarditis

Heart Failure - The Predominant Cardiovascular Complication

• Heart failure occurs in 42-60% of native valve endocarditis (NVE) cases 1
• More common when IE affects the aortic rather than mitral valve
• Primarily caused by:
  • New or worsening severe aortic or mitral regurgitation
  • Intracardiac fistulae
  • Valve obstruction (less common)

Hemodynamic Consequences

• Clinical presentation typically includes:
  • Dyspnea
  • Pulmonary edema
  • Cardiogenic shock 1
• Among patients with heart failure and IE, 66% present in New York Heart Association class III or IV 1
• Moderate to severe heart failure is the most important predictor of in-hospital, 6-month, and 1-year mortality 1

Recent Evidence on Hypertension and IE

A 2022 study published in Hypertension found that increased blood pressure may be a risk factor for developing IE 2. This study demonstrated:

• Incidence rates of IE per 100,000 person-years:

  • Normotension: 0.9
  • Prehypertension: 1.4
  • Hypertension: 2.6
  • Hypertension with medication: 6.0

• Those with elevated blood pressure showed increased risk of IE in a dose-response manner compared to normotensive individuals:

  • Prehypertension: HR 1.33 (95% CI, 1.06-1.68)
  • Hypertension: HR 1.98 (95% CI, 1.48-2.66)
  • Hypertension with medication: HR 2.56 (95% CI, 2.02-3.24) 2

Acute Management Considerations

When managing IE patients with cardiovascular complications:

• Echocardiography is crucial for:

  • Initial evaluation and follow-up
  • Assessment of valve perforation, secondary mitral lesions, and aneurysms
  • Evaluation of hemodynamic consequences of valvular dysfunction
  • Measurement of pulmonary artery pressure
  • Detection of pericardial effusion
  • Assessment of ventricular function 1

• Surgical intervention is indicated for:

  • Severe acute regurgitation causing pulmonary edema or cardiogenic shock (emergency surgery)
  • Severe regurgitation with symptoms of heart failure (urgent surgery)
  • Locally uncontrolled infection (urgent surgery) 1

Clinical Implications

While hypertension may be a risk factor for developing IE, once IE is established, patients are more likely to develop:

1. Heart failure with hypotension
2. Cardiogenic shock requiring vasopressor support
3. Valvular regurgitation leading to hemodynamic compromise

Important Caveats

• In patients with pre-existing hypertension who develop IE, blood pressure management becomes challenging due to:

  • Hemodynamic instability from valvular dysfunction
  • Potential for cardiogenic shock
  • Need for surgical intervention

• Repeat echocardiography is warranted when a patient develops worrisome clinical features during antibiotic therapy, including unexplained progression of heart failure symptoms, change in cardiac murmurs, and new atrioventricular block or arrhythmia 1

In conclusion, while hypertension may be a risk factor for developing IE, the actual clinical course of established IE is more commonly characterized by heart failure and hypotension rather than hypertension.