Endocarditis is caused by bacteria in the bloodstream multiplying and spreading across the inner lining of your heart (endocardium). The endocardium becomes inflamed, causing damage to your heart valves.
Your heart is usually well protected against infection so bacteria can pass harmlessly by. However, if your heart valves are damaged or you have an artificial valve, it’s easier for bacteria to take root and bypass your normal immune response to infection.
Small clumps of bacteria can develop at the site of the infection. There’s a risk of these clumps acting in a similar way to blood clots, travelling away from the heart and blocking the blood supply to the organs. This can cause organ failure or trigger a stroke.
How bacteria reach the heart
There are several ways that bacteria can enter your blood.
Everyday activities, such as brushing your teeth or chewing your food, can sometimes allow bacteria to enter the bloodstream. The risk is increased if your teeth and gums are in bad condition, because it makes it easier for bacteria to enter.
Bacteria can spread from the site of a pre-existing infection, such as a skin infection or a gum infection.
Bacteria can also enter your body as a result of a sexually transmitted infection (STI), such as chlamydia or gonorrhoea.
Needles and tubes
Any medical procedure that involves placing a medical instrument inside the body carries a small associated risk of introducing bacteria into your bloodstream.
Instruments that have been linked to endocarditis include:
catheters – a tube used to drain the bladder
the tubes used during dialysis – a treatment that involves replicating the functions of the kidneys
laparoscopes – a small, flexible tube with a light source and a camera at one end, used to help diagnose a wide range of conditions
Who’s at risk
There are a number of things that can make your heart more vulnerable to infection and increase your chances of developing endocarditis. These are discussed below.
Heart valve disease
Heart valve disease is a general term describing conditions that damage the valves of the heart. Two types of heart valve disease known to increase your risk of endocarditis are:
valvular stenosis – where the valve(s) of the heart become narrowed, disrupting the blood flow through the heart
valvular regurgitation – where the valve(s) of the heart don’t close properly, causing blood to leak back in the wrong direction
Heart valve disease can be either:
congenital – where you’re born with the condition
acquired – where you develop the condition in later life
Causes of acquired heart valve disease include:
a previous heart attack – a heart attack can damage the muscles that surround and support the valve, preventing the valves from functioning properly
high blood pressure – without treatment, high blood pressure (hypertension) can weaken the tissue around the valves
rheumatic fever – a type of bacterial infection that can damage the heart
Rheumatic fever is rare since the introduction of antibiotics. However, older people who had rheumatic fever during childhood may go on to develop heart valve disease.
Prosthetic (artificial) valves are used to replace heart valves that have been damaged by heart valve disease.
However, bacteria can also take root around prosthetic valves, which can occasionally trigger endocarditis. This risk is relatively low, estimated to be less than one in 100.
In hypertrophic cardiomyopathy, the heart muscle cells have enlarged and the walls of the heart chambers thicken. The chambers are reduced in size so they can’t hold much blood, and the walls can’t relax properly and may stiffen.
Hypertrophic cardiomyopathy is thought to affect 1 in 500 people in the UK.
Intravenous drug use
People who habitually inject illegal drugs such as heroin or methamphetamine (crystal meth) into their veins have an increased risk of developing endocarditis.
This is because unsterilised needles allow bacteria to enter the bloodstream and repeated injections make the skin more vulnerable to infection.
Endocarditis caused by a fungal infection is rarer than bacterial endocarditis, and usually more serious. You’re more at risk of fungal endocarditis if you:
have a history of heart surgery
have a central venous catheter – a tube connected to a vein in the neck, groin or chest, which is used to deliver medicines and/or fluids to people who are seriously ill
have a weakened immune system – either as a result of a condition affecting the immune system, such as HIV, or as a side effect of certain types of treatments, such as chemotherapy.