Page 77 - Medicine and Surgery

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Chapter 2: Hypertension and vascular diseases 73

Management carditis; this is due to changing patterns of the disease
It is important to identify the organism responsible (elderly, drug addicts, prosthetic valves, antibiotic resis-
for the endocarditis; however, this should be balanced tance).
with the need to treat promptly. Once cultures are sent,
intravenous antibiotics should be commenced based on
Hypertension and vascular
the most likely pathogens if there is a high suspicion of
bacterial endocarditis. diseases
Blind treatment includes benzylpenicillin or flu-

cloxacillin, and gentamicin for its synergistic effect, as Systemic hypertension
these will cover the most common organisms Staphy-
lococcus, Streptococcus and Enterococcus.Oral fusidic Definition
acid is added if Staphylococcus is suspected. Hypertension means high blood pressure (BP). The
When the culture results are known endocarditis
World Health Organisation latest guidelines define hy-
should be treated with the most appropriate antibi- pertension with three grades of severity that reflect the
otics. It is best to have a multidisciplinary approach fact that systolic and diastolic hypertension are indepen-
with early microbiological and surgical advice. dent risk factors for complications of hypertension:
It is usually necessary to continue antibiotic treatment
Grade 1 (mild): A systolic BP of ≥140 mmHg or a
for 6 weeks, but this may be converted to oral therapy diastolic BP of ≥90 mmHg.
after 2 weeks if the organism is sensitive. Grade 2 (moderate): A systolic BP of ≥160 mmHg or
Indications for surgical intervention in infective endo- a diastolic BP of ≥100 mmHg.
carditis to repair or replace valves: Grade 3 (severe): A systolic BP of ≥180 mmHg or a
Sufficient valve damage to cause symptomatic heart
diastolic BP of ≥110 mmHg.
failure.
Incidence
Persistent infection refractory to treatment, or relapse

Common. Up to 25% of the adult population is hyper-
following end of treatment.
tensive by these criteria.
Development of aortic root abscess (lengthening PR

interval).
Age
Fungal infection (large vegetations) rarely responds to

Increases with age (>50% affected over the age of 65
medical treatment alone.
years).
Multiple embolisation.

Prosthetic valves commonly require surgery together

Sex
with medical therapy.
M > F
The timing of surgery is a balance between the desire to
eradicatebacteriapriortotheprocedureandtheneedfor
early surgery due to the compromised haemodynamic Geography
state.Aftersurgeryafullcourseofdrugtreatmentshould Rising prevalence of hypertension in the developing
be given to eradicate the organisms. world, together with longer life expectancies, is increas-
Prophylactic treatment: Abnormal or prosthetic heart ing the morbidity of complications.
valves, patent ductus or septal defects and patients with
previous endocarditis are advised to have prophylactic Aetiology
oral or intravenous antibiotic cover for non-sterile pro- Divided into primary (essential) and secondary hyper-
cedures. For example, amoxycillin for dental procedures, tension:
and amoxycillin and gentamicin for oropharyngeal, gas- Essential hypertension (>90%)
trointestinal or genitourinary procedures. Non-modifiable: Genetic (racial and familial), gender
(males higher).
Prognosis Modifiable: Obesity, alcohol intake, diet (especially
Despite advances in treatment, overall mortality is still high salt intake).
15% and as high as 40–60% in prosthetic valve endo- Secondary hypertension (<10%)