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CME / ABIM MOC / CE

Did Endocarditis Associated With Drug Use Increase During COVID?

  • Authors: News Author: Megan Brooks; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 2/3/2023
  • Valid for credit through: 2/3/2024, 11:59 PM EST
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

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Target Audience and Goal Statement

This activity is intended for primary care physicians, infectious disease specialists, cardiologists, nurses, pharmacists, physician assistants, and other members of the healthcare team who care for patients at risk for endocarditis.

The goal of this activity is for learners to be better able to assess how COVID-19 might affect the risk for endocarditis among patients with opioid use disorder or cocaine use disorder.

Upon completion of this activity, participants will:

  • Evaluate the effects of COVID-19 on the risk for cardiovascular events
  • Assess how COVID-19 might affect the risk for endocarditis among patients with opioid use disorder or cocaine use disorder
  • Outline implications for the healthcare team


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News Author

  • Megan Brooks

    Freelance writer, Medscape

    Disclosures

    Megan Brooks has no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine

    Disclosures

    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor/Nurse Planner

  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.

Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Yaisanet Oyola, MD, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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CME / ABIM MOC / CE

Did Endocarditis Associated With Drug Use Increase During COVID?

Authors: News Author: Megan Brooks; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 2/3/2023

Valid for credit through: 2/3/2024, 11:59 PM EST

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Note: The information on the coronavirus outbreak is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available. It is the policy of Medscape Education to avoid the mention of brand names or specific manufacturers in accredited educational activities. However, manufacturer names related to the approved COVID-19 vaccines are provided in this activity in an effort to promote clarity. The use of manufacturer names should not be viewed as an endorsement by Medscape of any specific product or manufacturer.

Clinical Context

Like other inflammatory viral infections such as influenza, COVID-19 has been associated with an increased risk for cardiovascular (CV) events during the period of acute infection, but how long does this window of increased risk last? Xie and colleagues examined this issue in a large cohort of adults receiving health care at the US Veterans Affairs health system. Their results were published in the March 2022 issue of Nature Medicine.[1]

In comparing adults with a history of COVID-19 with contemporary control participants without COVID-19, the hazard ratio for major adverse cardiovascular events (MACE) during the period 30 to 365 days after SARS-CoV-2 infection was 1.55 (95% CI: 1.5, 1.6). Remarkably, COVID-19 had a lasting effect in association with a broad range of CV outcomes, including ischemic heart disease, cerebrovascular disease, thromboembolism, inflammatory heart disorders, and dysrhythmia. Moreover, CV risk increased with the severity of COVID-19.

There have been reports that COVID-19 may also increase the risk for endocarditis. The current study by Wang and colleagues examines this issue in a high-risk group: adults with a history of opioid use disorder (OUD) or cocaine use disorder.

Study Synopsis and Perspective

A new study provides more evidence that endocarditis associated with drug use is a significant and growing health concern and further demonstrates that this risk has been exacerbated by the COVID-19 pandemic.

The rate of infective endocarditis among individuals in the United States with OUD or cocaine use disorder increased in the 11-year period 2011 to 2022, with the steepest increase logged during the COVID-19 pandemic (2021-2022), according to the study.

A diagnosis of COVID-19 more than doubled the risk for a new diagnosis of endocarditis in patients with either cocaine (HR 2.24) or OUD (HR 2.23).

"Our data suggests that in addition to the major social disruption from the pandemic, including disrupted access to healthcare, COVID-19 infection itself is a significant risk factor for new diagnosis of endocarditis in drug using populations," wrote authors Nora Volkow, MD, director of the National Institute on Drug Abuse (NIDA), and colleagues.

"Drug using populations, particularly those who use cocaine or opioids, have some of the highest risk for endocarditis, and here we show that having a COVID-19 diagnosis further increases this risk," they added.

The study was published online December 13 in Molecular Psychiatry.[2]

The researchers analyzed electronic health record data collected from January 2011 through August 2022 for more than 109 million people across the United States, including more than 736,000 with an OUD and more than 379,000 with a cocaine use disorder.

In 2011, there were 4 cases of endocarditis per day for every 1 million people with OUD. By 2022, the rate had increased to 30 cases/d/1 million people with OUD.

Among individuals with cocaine use disorder or OUD, the risk of being hospitalized within 180 days after a diagnosis of endocarditis was higher in persons with than without COVID-19 (67.5% vs 58.7%; HR 1.21). 

The risk of dying within 180 days after a new diagnosis of endocarditis was also higher in persons with than without COVID-19 (9.2% vs 8%; HR 1.16).

The study also showed that Black and Hispanic individuals had a lower risk for COVID-19--associated endocarditis than non-Hispanic White individuals, which is consistent with a higher prevalence of injection drug use in non-Hispanic White populations compared with Black or Hispanic populations, the researchers pointed out.

Volkow and colleagues said their findings highlight the need to screen drug users for endocarditis and link them to infectious disease and addiction treatment if they contract COVID-19.

"People with substance use disorder already face major impediments to proper healthcare due to lack of access and stigma," Volkow said in a news release.[3]

"Proven techniques like syringe service programs, which help people avoid infection from re-used or shared injection equipment, can help prevent this often fatal and costly condition," Volkow added.

The authors said it will also be important to determine exactly how SARS-CoV-2 viral infection exacerbates the risk for endocarditis in drug users.

Support for the study was provided by the National Institute on Aging, National Institute on Alcohol Abuse and Alcoholism, the Clinical and Translational Science Collaborative of Cleveland, and the National Cancer Institute Case Comprehensive Cancer Center. The authors reported no relevant financial relationships.

Study Highlights

  • Researchers drew study from the TriNetX Analytics Network, which includes deidentified electronic health records from 109 million patients in 77 healthcare organizations, mostly large academic health systems.
  • Researchers examined rates of endocarditis by examining diagnosis codes from 2011 to 2022. They focused on how the prevalence of endocarditis changed during the COVID-19 pandemic and the interaction between OUD and cocaine use disorders and COVID-19 in promoting endocarditis.
  • Researchers could not focus on patients with methamphetamine use disorder because this diagnosis lacked a specific code.
  • COVID-19 was defined by either a positive laboratory test for SARS-CoV-2 or a diagnosis code for COVID-19.
  • Study results were adjusted to account for demographic and chronic disease variables, as well as COVID-19 vaccination and treatment.
  • The incidence of endocarditis increased from 3.7 cases/1 million persons/d in 2011 to 30.1 cases/1 million persons/d in 2022. There was a plateau in the incidence of endocarditis from 2017 to 2020, followed by an acceleration in cases during the COVID-19 pandemic.
  • The incidence rate of endocarditis was 3 to 8 times higher for patients with OUD or cocaine use disorder compared with patients without these diagnoses. In fact, the incidence of endocarditis was stable during the study period among patients without OUD or cocaine use disorder.
  • Researchers compared 49,331 patients with OUD diagnosed with COVID-19 with 405,959 patients with OUD who were not diagnosed with COVID-19. The respective numbers for patients with cocaine use disorder were 23,687 and 192,335.
  • Patients with COVID-19 were more likely to have more chronic medical conditions and worse socioeconomic circumstances.
  • The overall risks for endocarditis in comparing the OUD cohort with and without COVID-19 were 1.18% and 0.55%, respectively (HR 2.23 [95% CI: 1.92, 2.6]). The respective risks among patients with cocaine use disorder were 1.14% and 0.52% (HR 2.24 [95% CI: 1.79, 2.8]).
  • The clinical diagnosis of COVID-19 was more strongly associated with a higher risk for endocarditis compared with a positive test for SARS-CoV-2.
  • Hospitalization within 2 weeks of COVID-19 was associated with a higher risk for endocarditis among patients with OUD and cocaine use disorder, but COVID-19 vaccination status did not affect the risk for endocarditis.
  • The risk for endocarditis was lower in Black and Hispanic patients compared with White patients, but there was no difference in the risk for endocarditis based on gender.
  • The 180-day mortality risk among patients with endocarditis, OUD or cocaine use disorder, and a positive COVID-19 test was 9.2%. It was 8% among similar patients without COVID-19 (HR 1.16 [95% CI: 0.83, 1.61]).

Clinical Implications

  • A previous study by Xie found that the hazard ratio for MACE during the period 30 to 365 days after COVID-19 was 1.55 (95% CI: 1.5, 1.6). Remarkably, COVID-19 had a lasting effect in association with a broad range of CV outcomes, including ischemic heart disease, cerebrovascular disease, thromboembolism, inflammatory heart disorders, and dysrhythmia. Moreover, CV risk increased with the severity of COVID-19.
  • The current study by Wang and colleagues finds that the incidence rate of endocarditis increased nearly 10-fold from 2011 to 2022, driven largely by patients with substance use disorder. COVID-19 was an independent risk factor for endocarditis among patients with OUD and cocaine use disorder.
  • Implications for the healthcare team: The healthcare team should emphasize prevention of COVID-19, particularly among patients with OUD and cocaine use disorder.

 

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