Endocarditis and artificial heart valves: warning signs, tests and treatment

The NHS describes endocarditis as inflammation of the inner lining inside the heart, usually caused by an infection. It generally happens when bacteria or fungus gets into the bloodstream through the mouth or skin and travels to the heart, for example during a dental procedure or through a cut or graze.

The heart valves are part of that inner lining. An artificial valve is on the NHS list of things that increase risk, alongside valve disease, a pacemaker or implantable cardioverter defibrillator, certain types of congenital heart disease, hypertrophic cardiomyopathy, a heart transplant, previous endocarditis, working closely with farm animals and injecting illegal drugs.

The pages read for this guide do not describe prosthetic valve endocarditis as a separate disease, so the information below follows the NHS and NICE guidance on endocarditis in general, with the points that matter most to people who have a replacement valve.

NICE guideline CG64 asks healthcare professionals to regard people with the following conditions as being at increased risk of developing infective endocarditis.

• Acquired valvular heart disease with stenosis or regurgitation.

• Hypertrophic cardiomyopathy.

• Previous infective endocarditis.

• Structural congenital heart disease, including surgically corrected or palliated conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect, fully repaired patent ductus arteriosus and closure devices judged to be endothelialised.

• Valve replacement.

The NHS lists a high temperature or feeling hot, cold or shivery, headaches, feeling very tired, joint or muscle pain, regular night sweats, breathlessness, and loss of appetite or unintentional weight loss. There may also be small dark spots on the skin, red spots on the palms or soles of the feet (less obvious on brown or black skin), small dark spots or lines under the fingernails, small painful lumps on the fingers or toes, and chest or back pain.

Because these symptoms can be vague and develop gradually, a person with an artificial valve who has an unexplained fever, sweats or tiredness lasting more than a short time should say so to their GP and mention the valve. The NHS advises getting help from NHS 111 if you have symptoms of endocarditis.

Call 999 if you or someone with you has face weakness, weakness or numbness in one arm or down one side of the body, speech problems, or blurred vision or loss of sight in one or both eyes. These can be signs of a stroke, which the NHS says can be a complication of endocarditis and needs treating immediately.

A doctor will examine you, listen to your chest and ask about recent dental treatment or other medical procedures. If endocarditis is suspected, the NHS says you will usually be referred to a heart specialist (cardiologist).

Tests usually happen in hospital and aim to identify the germ responsible, see how the heart is working and look for damage. They may include blood and urine tests, a chest X-ray, an electrocardiogram and echocardiogram, and an MRI scan.

The NHS says treatment usually involves medicine and sometimes surgery. Antibiotic or antifungal medicine is given for 4 to 6 weeks, usually through a drip or injection into a vein at the start. If you feel well enough and tests show the infection is under control, you may be able to finish the IV medicine at home, with help from a friend, family member, carer or district nurse, or by doing it yourself. Some people continue tablets for a few more weeks.

Around half of people with endocarditis will need surgery to remove or repair damaged heart tissue or valves. Depending on where the infection is, a pacemaker may be fitted, or an existing pacemaker removed and replaced. For someone who already has an artificial valve, doctors will weigh up whether medicine alone is enough or whether surgery on the valve is needed.

The NHS says many people fully recover, particularly if the infection is found and treated early, but it can take several months to feel completely better, especially after surgery, and it is normal to feel very tired for several weeks after treatment.

You will need regular check-ups and blood tests during and after recovery to make sure the infection has gone and to look for damage that could cause complications such as heart failure. Having endocarditis also raises the chance of stroke, and of getting endocarditis again, so knowing the symptoms and acting quickly if they return is important.

NICE says that people at increased risk should be offered clear and consistent information about prevention, including the benefits and risks of antibiotic prophylaxis and why it is no longer routinely recommended, the importance of good oral health, the symptoms that may indicate infective endocarditis and when to seek advice, and the risks of invasive procedures including non-medical ones such as body piercing or tattooing.

Specifically, NICE says antibiotic prophylaxis is not recommended routinely for people undergoing dental procedures or for non-dental procedures involving the gastrointestinal tract, genitourinary tract (including childbirth) or upper and lower respiratory tract. It says chlorhexidine mouthwash should not be offered as prophylaxis before dental procedures. For people at high risk undergoing dental procedures, NICE points to the Scottish Dental Clinical Effectiveness Programme advice, which is endorsed for use across the UK by the Chief Dental Officers.

NICE also says that any episode of infection in someone at risk should be investigated and treated promptly. The NHS adds practical steps: take care of teeth and gums and attend regular dental check-ups, speak to a doctor before dental procedures if advised, properly clean and cover cuts and grazes, wash hands regularly, and avoid piercings or tattoos without speaking to a doctor first.

Suspected endocarditis is investigated and treated in hospital, and the NHS says you will usually be referred to a cardiologist. Follow-up check-ups and blood tests after treatment are part of NHS care.

Some people use private cardiology or dental services for routine review. Whatever the route, tell every dentist and doctor that you have an artificial heart valve.