Definition

Endocarditis refers to inflammation of the lining membrane of the heart. The infection is usually confined to the covering of a valve and sometimes the lining membrane of the chambers known as the endocardium. The condition is generally classified by its clinical course as acute endocarditis, and subacute endocarditis (duration of more than six weeks).

Etiology

In acute endocarditis, the causes may be group A non-hemolytic streptococcus, pneumococcus, staphylococcus, and rarely gonococcus organisms. The condition usually results from bacteremia that follows septic thrombophlebitis; open-heart surgery involving prosthetic valves; and skin, bone, and pulmonary infections. It may also occur in intravenous (IV) drug abusers, or result from a fungal invasion. Subacute bacterial endocarditis is usually caused by streptococcus organisms, which are usually found in the gastrointestional (GI) tract and perineal flora. The condition may also follow dental, genitourinary, gynecologic, and gastrointestinal procedures.

Signs & Symptoms

Early signs and symptoms may include: weakness, fatigue, weight loss, anorexia, arthralgia, night sweats, intermittent fever, and a loud regurgitant heart murmur. There may also be small, purplish petechiae on the skin, buccal, pharyngeal, or conjunctival mucosa; anemia; malaise; vomiting; and chills. A number of other symptoms which may be present in subacute endocarditis include: embolization from the bacteria on the valves of the heart, bacteremia, and metastic foci of infection. As a result of the embolization, other clinical features which may occur include: splenic, renal, cerebral, or pulmonary infarction. The emboli may produce stroke; myocardial infarction (MI); flank pain and hematuria; abdominal pain; or acute arterial insufficiency in an extremity. There also may be signs and symptoms of peripheral vascular occlusion and congestive heart failure (CHF).

The functional abilities of cardiac patients can be classified in terms of metabolic equivalents (METs). The classification is generally as follows:

• Light to medium housework is 2 to 4 METs

• Heavy housework or yard work is approximately 5 to 6 METs

• Strenuous activity would be 7 to 10 METs, etc.

To determine the limitations on patient's functional abilities, the METs are considered in accordance with what symptoms are exhibited when the activities are carried out. For example, if a patient is performing activity at the 2 to 4 MET level and experiences dyspnea, fatigue, dizziness or fainting, the patient is considered to have low functional abilities.

Tests

Tests for endocarditis include: three or more blood cultures during a 24- to 48-hour period; electrocardiogram (EKG); blood tests which show elevated white blood cells (WBC), abnormal histiocytes, and elevated erythrocyte sedimentation rate (ESR); and normochromic anemia. In addition, confirmation of valvular infection can sometimes be made with visualization of vegetation on the valves via transthoracic or transesophageal echocardiograms since blood cultures can be negative in two to five percent of the cases.

Treatment

Treatment of endocarditis is focused on removal of the infecting organism. This can take several weeks. Appropriate antibiotics are selected based on specific conditions and suspected organisms. Antibiotic therapy continues for approximately 4 weeks. When the valves are involved, surgical debridement of infected tissue around the valves and replacement of the valves may be indicated. The treatment plan may also include bed rest, aspirin, and adequate fluid intake. If severe valvular damage has resulted, a cardiac prosthesis, or corrective surgery may become necessary.

Residuals

Residuals will vary ranging from no residuals to any combination of the signs and symptoms. The most common complication is chronic CHF.

Special Considerations

• May be entitled to special monthly compensation where the Veteran has a single service-connected disability rated as 100% with additional service-connected disability or disabilities independently ratable at 60% or more, which are separate and distinct from the 100% service-connected disability and involves different anatomical segments or bodily systems. See  38 CFR 3.350 (i) (1) – Total plus 60% – Special Monthly Compensation (SMC).

• This disease shall be granted service connection although not otherwise established as incurred in or aggravated by service if manifested to a compensable degree within the applicable time limits under 38 CFR 3.307 following service in a period of war or following peacetime service on or after January 1, 1947, provided the rebuttable presumption provisions of 38 CFR 3.307 are also satisfied [ 38 CFR 3.309 .  [Disease subject to presumptive service connection], 38 CFR 3.309 (a) [chronic disease].

Notes

• Evaluate cor pulmonale, which is a form of secondary heart disease, as part of the pulmonary condition that causes it.

• One MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which breathlessness, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, a medical examiner may estimate the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in those symptoms.

• For this general formula, heart failure symptoms include, but are not limited to, breathlessness, fatigue, angina, dizziness, arrhythmia, palpitations, or syncope.

• The rating criteria for cardiovascular conditions underwent full-scale revision effective on November 14, 2021 and January 12, 1999.  A regulatory change was effective August 13, 1998, updated criteria for cold injury residuals under 38 CFR 4.104, DC 7122.  The changes are not considered liberalizing and should not be used as the basis for reduction unless the disability has actually improved.