America's ongoing opioid crisis has led to a rising incidence of drug use-associated infective endocarditis (DUA-IE) among persons who inject drugs (PWID).^1,2 Cardiologists are a key part of the multidisciplinary effort required to care for DUA-IE, alongside experts in addiction medicine, infectious disease, cardiac surgery, internal medicine, psychiatry, social work, case management, and nursing.

To meet this growing need there has been a call for specialized teams focused on PWID with IE that integrate the skills of these providers to ensure holistic, non-biased, timely, and individualized care. This is especially important given the lack of randomized trials in this population.³

Cardiology fellows-in-training (FITs) can function as institutional champions to lead efforts to optimize the care of patients with DUA-IE. I asked three experts for their insights and advice.

What advice do you have for cardiology fellows caring for patients with DUA-IE?

Evin Yucel, MD, Cardiologist, Massachusetts General Hospital (MGH); MGH Drug Use Endocarditis Treatment (DUET) Team Member:

"Caring for patients with DUA-IE highlights the importance of a holistic approach. Recognizing that their heart disease is a consequence of their substance use disorder (SUD) is crucial to their care."

"Unfortunately, there are a lot of challenges for cardiologists. Most importantly, in my perspective, is that we are not routinely trained in trauma-informed care, which I believe is a key to success when caring for patients with DUA-IE."

"Many institutions now have multidisciplinary teams dedicated to patients with DUA-IE. If a team is already in place, I would advise the fellows to be engaged. If not, then they have a great opportunity to start something new."

Robin Lennox, MD, Co-Head of Inpatient Addiction Medicine Service, Hamilton Health Sciences, Ontario, Canada; Lead Investigator of the Second Heart Program for PWID with IE:⁴

"Learn how to speak in a non-stigmatizing, respectful, and person-centered manner. Learn about harm reduction practices and discuss these with patients, including how to use naloxone kits and safer injection practices. Whenever possible, learn how to prescribe medications for opioid use disorder [MOUD] and offer them to patients."

Ben Bearnot, MD, Addition Medicine Physician; MGH DUET Team member:

"Think of the patient's SUD as an underlying 'source' of the infection. Regardless of how effectively we manage their hemodynamics, valvular dysfunction, or infection, without addressing the underlying SUD we're likely to see these patients return with recurrent infections."

"Reach out to the other team-members to start a conversation; multidisciplinary team approaches are rapidly becoming the standard of care for DUA-IE, and this approach can be started informally even before a team is founded at your institution."

"Cardiology fellowship is a great opportunity to learn new skills while honing existing ones. I'd recommend that fellows work on exclusively using person-first, non-stigmatizing language. Our recent article has a table summarizing phrases that can be used to minimize stigma and discrimination."⁵

"I'd also recommend that fellows seek out opportunities for training in trauma-informed care. Hospitalizations are often challenging experiences for PWID, leading to high rates of patient-directed discharges. It is important for all team members, including cardiologists, to facilitate positive interactions with this vulnerable group."

"Lastly, I'd recommend that FITs become comfortable with buprenorphine. Buprenorphine is easy to prescribe and has been consistently shown to reduce all-cause mortality by more than 50% when continuously used by people with opioid use disorder."

What advice do you have for FITs interested in advancing care for PWID through quality improvement or research?  How can programs support fellows?

Dr. Lennox:

"At an institutional level, cardiologists advocating for inpatient addiction medicine consult teams can go a long way to ensure that all patients with DUA-IE are offered gold standard treatment. Fellows can advocate for their institution to adopt policies that further a harm reduction approach. Specific to DUA-IE, care can be optimized by advocating that PWID are offered the standard of care treatment for their infection, including surgery without delay or conditions, indwelling lines for antibiotics when indicated, and treatment of underlying SUD."

Dr Yucel:

"I think cardiologists should be leaders in reducing stigmatization of PWID inside and outside of their institutions. Including this topic in the didactic educational curriculum is essential. Fellows should be encouraged to participate in the multidisciplinary discussions and the care of DUA-IE in the inpatient and outpatient settings."

"DUA-IE is difficult to study scientifically as it is a complex disease that can have various presentations, and each patient is unique. Psychosocial and environmental aspects of patients' lives play a key role in their disease process. Patients referred to tertiary care centers may not be followed there, making long term data acquisition challenging. Creating regional workgroups and registries could be helpful. Interested fellows could take the lead on this. Opportunities are endless when it comes to supporting motivated FITs."

So how can an interested FIT use this advice to become a catalyst for change?

First, educate yourself: stay atop the latest literature. Become familiar with trauma-informed care, MOUD, harm reduction, and person-first, non-stigmatizing language. Ask to see as many inpatient consults for DUA-IE as possible. Review imaging with expert faculty. Talk to your clinic preceptor and offer to be the longitudinal cardiology follow up these patients often lack.

Second, engage in multidisciplinary collaboration: identify fellows from other relevant specialties who share your passion. Ask them to become co-champions in improving DUA-IE care. Find faculty allies. Formalize an interdisciplinary team that is able to meet to discuss cases in real-time. Take the lead on solving the logistical challenges as they arise.

Third, pursue scholarship: use the team as the basis for a short-term quality improvement or research project. Demonstrate value by providing evidence that your efforts are having a positive effect, no matter how modest.

Finally, engage and advocate: spread the word about the team by sending emails, posting flyers, and making announcements during conferences. Invite residents and students to join meetings. Recruit local and national experts and host multidisciplinary grand rounds.

A motivated FIT who adopts this approach will gain leadership, clinical, and research skills. By helping to build a stigma-free, compassionate, and effective care environment for our most vulnerable patients, they will have an impact that will last well beyond their training.

Interviews have been edited for space and clarity.

References

1. Kadri AN, Wilner B, Hernandez AV, et al. Geographic trends, patient characteristics, and outcomes of infective endocarditis associated with drug abuse in the United States from 2002 to 2016. J Am Heart Assoc 2019;Sep 18:[ePub ahead of print].
2. Fleischauer AT, Ruhl L, Rhea S, Barnes, E. Hospitalizations for endocarditis and associated health care costs among persons with diagnosed drug dependence - North Carolina, 2010-2015. MMWR Morb Mortal Wkly Rep 2017;66:569-573.
3. Paras ML, Wolfe SB, Bearnot B, et al; Drug Use Endocarditis Treatment Team Working Group. Multidisciplinary team approach to confront the challenge of drug use–associated infective endocarditis. J Thorac Cardiovasc Surg 2021;Nov 05:[ePub ahead of print].
4. Second Heart Program (McMaster University). 2022. Available at: https://fammed.mcmaster.ca/research/research-programs-projects/care-of-people-who-use-drugs/. Accessed 10/03/2022.
5. Yucel E, Bearnot B, Paras ML, et al. Diagnosis and management of infective endocarditis in people who inject drugs: JACC State-of-the-Art Review. J Am Coll Cardiol 2022;79:2037–57.

Clinical Topics: Cardiovascular Care Team, Valvular Heart Disease

Keywords: Buprenorphine, Inpatients, Outpatients, Teaching Rounds, Naloxone, Patient Discharge, Leadership, Anti-Bacterial Agents, Follow-Up Studies, Drug Users, Substance Abuse, Intravenous, Endocarditis, Heart Diseases, Faculty, Psychiatry, Registries, Hemodynamics, Patient Care Team, Communicable Diseases

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