Surgery for infective endocarditis can be safely performed with low mortality rates in persons who inject drugs (PWID), but addiction to the drugs themselves is extremely lethal – much more so than the surgery – a new study reveals. These data were reported by Michael J. Javorski, MD, MS, of the Cleveland Clinic, and colleagues in a manuscript published Monday online and in the Feb. 27 issue of the Journal of the American College of Cardiology. Two potentially lethal diseases are present in PWID and require surgery for infective endocarditis. The opioid epidemic in the U.S. has led to increased injection drug use, putting people at risk for infections, particularly infective endocarditis. Rates of infective endocarditis have risen since the epidemic began, causing surgical, psychosocial, ethical and decision-making difficulties. Current rehabilitation efforts do little to prevent patient loss to follow-up, relapse of injection drug use and death. The purpose of this study was to examine the demographics and outcomes of PWID who underwent cardiac surgery for infective endocarditis. The patients underwent surgery at quaternary hospitals that focused on developing and implementing addiction management programs. Between January 1, 2010, and June 1, 2020, a total of 227 PWID (mean age=36 years, 42.7% female; 90.4% white, 5.9% Black) underwent surgery for infective endocarditis at a quaternary hospital. Competing risks and risk factors were assessed: postsurgery loss to follow-up, drug relapse and death. These were identified parametrically and through machine learning. One standard deviation was used for the confidence interval [CI], so the CI was 68%. The most self-reported injected drug was heroin (81%). Homelessness (25%), justice system involvement (66%), depression (52%), anxiety (46%) and post-traumatic stress disorder (15%) were all reported psychosocial issues in PWID. Four PWID in this cohort died in the hospital. Prescription medication at discharge increased from 0% (2010) to 100% (2020). At 1- and 5-year follow-up, conditional probabilities of loss to follow-up were 16% (68% CI =13%-22%) and 59% (68% CI=44%-65%), drug relapse was 32% (68% CI=28%-34%) and 79% (68% CI=74%-83%) and mortality was 21% (68% CI=18%-23%) and 68% (68% CI=62%-72%). Key predictors of relapse were younger age, heroin use and lower levels of education. Overall, the lethality of addiction was more lethal than infective endocarditis alone in PWID who required infective endocarditis surgery. Several underlying issues, such as social, educational, psychiatric and psychological problems, led to an even higher mortality rate in this young population of PWID. In an accompanying editorial, Krish C. Dewan, MD, and Carmelo A. Milano, MD, both of Duke University Medical Center, Durham, North Carolina, examined the opioid epidemic from a cardiac surgery standpoint and pointed out the common causes of death in PWID. They also acknowledged the lethal interplay of infection and addiction. “The data presented by Javorski et al is sobering. Should the lack of any measurable survival or relapse benefit discourage others from attempting large-scale multidisciplinary efforts? No—the truth of the matter is that it may be too early to decipher the true effect of the organized addiction management program described,” the editorialists wrote. The editorialists concluded that new programs and studies need to guide further development of addiction management strategies and, until then, we must accept that there is “unfortunately no silver bullet” for treating the PWID population. Sources: Javorski MJ, Rosinski BF, Shah S, et al. Infective Endocarditis in Patients Addicted to Injected Opioid DrugsJ Am Coll Cardiol. 2024;83:811-823. Dewan KC, Milano CA. Infective Endocarditis, Substance Use Disorder, and Relapse: There Is No Silver Bullet. J Am Coll Cardiol. 2024;83:824-826. Image Credit: jetcityimage – stock.adobe.com