Heart Inflammation: Myocarditis, Pericarditis & Endocarditis

What Is Heart Inflammation and What Are the Different Types?

Heart inflammation encompasses three main conditions: myocarditis (inflammation of the heart muscle), pericarditis (inflammation of the sac surrounding the heart), and endocarditis (inflammation of the heart valves and inner lining). Each type has distinct causes, symptoms, and treatments, though viral infections are the most common trigger for myocarditis and pericarditis.

The heart is a complex organ with multiple layers, each susceptible to inflammation. Understanding the different types of heart inflammation is crucial for proper diagnosis and treatment. When the heart becomes inflamed, its ability to pump blood efficiently can be compromised, leading to symptoms ranging from mild discomfort to life-threatening complications.

Heart inflammation can occur at any age but certain types are more common in specific populations. Myocarditis and pericarditis frequently affect young adults, particularly after viral infections, while endocarditis is more common in people with pre-existing heart valve abnormalities, artificial heart valves, or those who use intravenous drugs. The inflammation can be acute (sudden onset) or chronic (long-lasting), and understanding the timeline of symptoms helps guide treatment decisions.

The prognosis for heart inflammation varies widely depending on the type, cause, and severity. While many cases of viral pericarditis resolve completely within weeks, some forms of myocarditis can lead to permanent heart damage or heart failure. Early recognition and appropriate treatment are essential for optimal outcomes.

Myocarditis - Inflammation of the Heart Muscle

Myocarditis occurs when the myocardium, the muscular middle layer of the heart wall, becomes inflamed. This inflammation can weaken the heart muscle, reducing its ability to pump blood effectively and potentially causing abnormal heart rhythms (arrhythmias). The condition can range from mild with minimal symptoms to severe, life-threatening disease requiring intensive care.

The inflammation in myocarditis typically results from the immune system's response to an infection, most commonly viral. When a virus infects heart muscle cells, the body mounts an immune response that, while trying to eliminate the pathogen, can inadvertently damage the heart tissue. In some cases, the immune response continues even after the infection has cleared, leading to ongoing inflammation and heart damage.

Myocarditis affects approximately 10-22 per 100,000 people annually worldwide. It is a significant cause of sudden cardiac death in young adults and athletes, accounting for up to 20% of cases. The condition can occur as an isolated event or as part of a systemic illness affecting multiple organs.

Pericarditis - Inflammation of the Heart Sac

Pericarditis involves inflammation of the pericardium, the thin two-layered sac that surrounds and protects the heart. The pericardium normally contains a small amount of fluid that lubricates the heart's movement during beating. When inflamed, the pericardial layers can rub against each other, causing the characteristic sharp chest pain, or excessive fluid can accumulate (pericardial effusion), potentially compressing the heart.

Acute pericarditis is one of the most common causes of chest pain presenting to emergency departments, accounting for approximately 5% of all chest pain visits. The condition is more prevalent in men and typically affects adults between 20 and 50 years of age. While most cases are self-limiting and resolve with appropriate treatment, recurrent pericarditis affects about 15-30% of patients and can become a chronic problem.

The hallmark of pericarditis is pleuritic chest pain - sharp pain that worsens with breathing, coughing, or lying flat, and improves when sitting up and leaning forward. This positional quality helps distinguish pericarditis from other causes of chest pain, including heart attack, though both conditions require prompt medical evaluation.

Endocarditis - Inflammation of the Heart Valves

Endocarditis is an infection of the endocardium, the inner lining of the heart chambers and valves. Unlike myocarditis and pericarditis, which are often caused by viral infections, endocarditis is typically caused by bacteria that enter the bloodstream and attach to damaged or abnormal heart valves. Fungal endocarditis is less common but can occur in immunocompromised individuals.

This condition is particularly serious because bacteria can form vegetations (clumps of bacteria, blood cells, and debris) on the heart valves. These vegetations can damage the valves, cause heart failure, and break off to travel through the bloodstream (emboli), potentially causing strokes, organ damage, or other serious complications.

Infective endocarditis has an incidence of approximately 3-10 per 100,000 people annually and is associated with significant mortality rates of 15-30% despite modern treatment. Risk factors include artificial heart valves, congenital heart defects, previous endocarditis, intravenous drug use, poor dental hygiene, and certain medical procedures.

What Causes Heart Inflammation?

Heart inflammation is most commonly caused by viral infections, including common cold viruses, COVID-19, and influenza. Other causes include bacterial and fungal infections, autoimmune diseases, certain medications, and in many cases, the cause remains unknown (idiopathic). Understanding the underlying cause is crucial for appropriate treatment.

The causes of heart inflammation vary depending on which part of the heart is affected, though there is significant overlap. Identifying the specific cause helps guide treatment decisions and predict outcomes. In many cases, particularly with viral myocarditis and pericarditis, the inflammation develops following a respiratory or gastrointestinal infection, though symptoms may appear days to weeks after the initial illness has resolved.

The immune system plays a central role in heart inflammation. In viral infections, the immune response to the virus can damage heart tissue. In autoimmune conditions, the immune system mistakenly attacks the heart. Understanding these mechanisms has led to the development of immunomodulatory treatments for certain forms of heart inflammation.

Viral Infections

Viruses are the most common cause of myocarditis and pericarditis in developed countries. A wide range of viruses can cause heart inflammation, with different viruses predominating in different time periods and geographic regions.

• Enteroviruses: Coxsackievirus B is historically the most commonly identified cause of viral myocarditis
• Adenoviruses: Common respiratory viruses that can affect the heart
• Parvovirus B19: Known to cause myocarditis, particularly in children
• Human herpesvirus 6 (HHV-6): Increasingly recognized as a cause of myocarditis
• COVID-19 (SARS-CoV-2): Associated with myocarditis and pericarditis in some patients
• Influenza: Can cause myocarditis, particularly during severe infections
• HIV: Associated with various forms of cardiac involvement
• Hepatitis C: Can cause myocarditis in some cases

COVID-19 has brought increased attention to viral myocarditis. Studies show that myocarditis occurs in approximately 1-2 per 1,000 COVID-19 infections, with higher risk in those with severe disease. The condition has also been reported as a rare side effect of mRNA COVID-19 vaccines, primarily in young males, though the risk is significantly lower than that associated with COVID-19 infection itself.

Bacterial Infections

Bacterial infections are the primary cause of endocarditis and can occasionally cause myocarditis or pericarditis. In endocarditis, bacteria enter the bloodstream through various routes - dental procedures, skin infections, intravenous drug use, or certain medical procedures - and colonize the heart valves.

The most common bacteria causing endocarditis include Staphylococcus aureus (especially in intravenous drug users and those with healthcare-associated infections), Streptococcus viridans (often from dental sources), and Enterococcus species. Bacterial pericarditis, though less common than viral, can occur as a complication of pneumonia or other systemic infections and requires aggressive antibiotic therapy.

Autoimmune and Inflammatory Conditions

Various autoimmune diseases can cause heart inflammation as part of systemic inflammation. Conditions such as systemic lupus erythematosus (SLE), rheumatoid arthritis, sarcoidosis, and inflammatory bowel disease are associated with increased risk of pericarditis and myocarditis. In these conditions, the immune system attacks the body's own tissues, including the heart.

Certain inflammatory conditions specifically target the heart. Giant cell myocarditis is a rare but aggressive form of myocarditis characterized by the presence of giant cells in the heart muscle. Eosinophilic myocarditis is associated with allergic reactions and eosinophilia. These conditions often require immunosuppressive therapy in addition to standard heart failure treatments.

Medications and Toxins

Certain medications can cause heart inflammation through various mechanisms. Drug-induced myocarditis can result from hypersensitivity reactions or direct toxic effects on the heart. Cancer chemotherapy drugs, particularly anthracyclines (like doxorubicin) and some newer immunotherapy agents (checkpoint inhibitors), are well-known causes of cardiac inflammation and damage.

Other medications associated with heart inflammation include certain antibiotics (particularly sulfonamides and penicillins), antipsychotic medications (clozapine), anticonvulsants, and some illegal drugs (cocaine, amphetamines). Radiation therapy to the chest can also cause pericarditis, either acutely during treatment or years later as delayed radiation-induced pericarditis.

What Are the Symptoms of Heart Inflammation?

Symptoms of heart inflammation include chest pain (sharp and worsening with breathing in pericarditis, or dull and persistent in myocarditis), shortness of breath, fatigue, fever, palpitations, and swelling in the legs. Symptoms often appear after a viral illness. Myocarditis can mimic a heart attack with similar symptoms requiring emergency evaluation.

The symptoms of heart inflammation vary depending on which part of the heart is affected, the severity of inflammation, and the underlying cause. Many patients report a recent viral illness - typically an upper respiratory infection or gastrointestinal illness - in the days to weeks before cardiac symptoms develop. Recognizing these symptoms early is crucial, as prompt treatment can prevent complications and improve outcomes.

It's important to note that heart inflammation can present with varying degrees of severity. Some patients have minimal symptoms and may not realize they have a heart condition, while others present with life-threatening complications. The unpredictable nature of these conditions underscores the importance of seeking medical evaluation for any concerning cardiac symptoms.

Symptoms of Pericarditis

Pericarditis has a distinctive symptom pattern that often allows clinical diagnosis. The hallmark is chest pain with specific characteristics:

• Sharp, stabbing chest pain: Often localized to the left side or center of the chest
• Pain worsens with breathing: Deep inspiration, coughing, or swallowing can intensify the pain
• Position-dependent pain: Worse when lying flat, better when sitting up and leaning forward
• Pain may radiate: To the shoulders, neck, or back
• Fever: Low-grade fever is common with infectious causes
• General malaise: Fatigue, weakness, and feeling unwell
• Shortness of breath: Especially if significant fluid accumulates around the heart

If large amounts of fluid accumulate in the pericardial space (pericardial effusion), additional symptoms may develop including muffled heart sounds, low blood pressure, and distended neck veins. In severe cases, this can progress to cardiac tamponade - a life-threatening condition where fluid compresses the heart and prevents it from filling properly.

Symptoms of Myocarditis

Myocarditis symptoms are often more variable and can sometimes mimic a heart attack. The presentation depends on the severity of heart muscle involvement:

• Chest pain or discomfort: May be pressure-like, similar to angina or heart attack
• Shortness of breath: At rest or with minimal exertion, may worsen when lying down
• Fatigue: Often profound and out of proportion to activity level
• Palpitations: Awareness of rapid, irregular, or skipped heartbeats
• Lightheadedness or fainting: Due to arrhythmias or reduced heart function
• Swelling: In the legs, ankles, or feet due to fluid retention
• Flu-like symptoms: Recent or concurrent fever, muscle aches, sore throat, or diarrhea

In severe cases, myocarditis can cause sudden cardiac death, particularly in young athletes during exercise. This is why activity restriction is such an important part of treatment. Some patients develop cardiogenic shock - severe heart failure with dangerously low blood pressure - requiring intensive care and mechanical circulatory support.

Symptoms of Endocarditis

Endocarditis typically has a more insidious onset with symptoms developing over weeks to months. The symptoms result from both the infection itself and its complications:

• Fever and chills: Often the first and most consistent symptom
• Night sweats: Particularly common with subacute endocarditis
• Fatigue and weakness: Persistent and progressive
• Weight loss: Unintentional weight loss over time
• New or changing heart murmur: Due to valve damage
• Shortness of breath: From heart failure or lung involvement
• Petechiae: Small red spots on the skin, mucous membranes, or eyes
• Splinter hemorrhages: Red-brown lines under the fingernails
• Painful nodules on fingers or toes: Osler nodes or Janeway lesions

How Is Heart Inflammation Diagnosed?

Heart inflammation is diagnosed through a combination of medical history, physical examination, blood tests (troponin, inflammatory markers), ECG, echocardiogram, and cardiac MRI. Cardiac MRI is the gold standard for diagnosing myocarditis, with 76% sensitivity and 96% specificity. Blood cultures are essential for diagnosing endocarditis.

Diagnosing heart inflammation requires a systematic approach combining clinical assessment with various diagnostic tests. The initial evaluation focuses on distinguishing cardiac causes of chest pain from other conditions and determining which type of heart inflammation is present. Because the symptoms can overlap with other serious conditions, including heart attack, a thorough evaluation is essential.

The diagnostic workup is guided by the suspected type of heart inflammation. While some tests are common to all forms, others are specific to particular conditions. Modern imaging techniques, particularly cardiac MRI, have revolutionized the diagnosis of myocarditis and pericarditis, allowing non-invasive visualization of inflammation and tissue damage.

Blood Tests

Blood tests provide crucial information about inflammation, heart damage, and potential causes:

• Troponin: Elevated levels indicate heart muscle damage and are present in most cases of myocarditis
• Inflammatory markers: C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are typically elevated
• Complete blood count: May show elevated white blood cells or specific cell patterns
• BNP or NT-proBNP: Elevated in heart failure, indicating compromised heart function
• Blood cultures: Essential for diagnosing endocarditis - multiple sets are drawn to identify the causative organism
• Viral serology: May help identify the causative virus in myocarditis
• Autoimmune panel: If autoimmune causes are suspected

Electrocardiogram (ECG)

An ECG records the electrical activity of the heart and is one of the first tests performed. Findings vary depending on the type of heart inflammation:

Pericarditis ECG findings: Diffuse ST-segment elevation, PR depression, and characteristic evolution through stages. Unlike heart attack, the ST changes are widespread rather than localized to specific coronary territories.

Myocarditis ECG findings: Variable and may include ST changes (elevation or depression), T-wave inversions, arrhythmias (including heart blocks and ventricular arrhythmias), and low voltage. The ECG may also appear normal despite significant inflammation.

Echocardiogram

Echocardiography uses ultrasound to visualize the heart's structure and function. This non-invasive test provides valuable information:

• Heart function: Ejection fraction and wall motion abnormalities in myocarditis
• Pericardial fluid: Detection and quantification of pericardial effusion
• Valve function: Identification of valve damage and vegetations in endocarditis
• Structural abnormalities: Chamber enlargement or thickening

Transesophageal echocardiography (TEE), which uses a probe passed into the esophagus, provides clearer images of the heart valves and is particularly useful for diagnosing endocarditis and small vegetations not visible on standard transthoracic imaging.

Cardiac MRI

Cardiac magnetic resonance imaging (CMR) has become the gold standard for diagnosing myocarditis. Using specialized imaging sequences, cardiac MRI can detect:

• Myocardial edema: Swelling of the heart muscle indicating acute inflammation
• Late gadolinium enhancement: Areas of scarring or fibrosis
• Hyperemia: Increased blood flow indicating inflammation
• Pericardial involvement: Thickening, enhancement, or effusion

The Lake Louise Criteria, updated in 2018, provide standardized diagnostic criteria for myocarditis using cardiac MRI. The test has approximately 76% sensitivity and 96% specificity for diagnosing myocarditis, making it the most accurate non-invasive diagnostic tool available.

How Is Heart Inflammation Treated?

Treatment depends on the type and cause of heart inflammation. Pericarditis is treated with NSAIDs and colchicine. Myocarditis primarily requires rest, activity restriction, and supportive care for heart failure. Endocarditis requires prolonged intravenous antibiotics (4-6 weeks) and sometimes surgery. Severe cases may need intensive care and mechanical circulatory support.

The treatment approach for heart inflammation varies significantly depending on which part of the heart is affected, the underlying cause, and the severity of the condition. While some cases require only anti-inflammatory medications and rest, others necessitate hospitalization, aggressive medical therapy, or even surgery. The goals of treatment include reducing inflammation, managing symptoms, preventing complications, and addressing the underlying cause.

A multidisciplinary approach involving cardiologists, infectious disease specialists (for endocarditis), and sometimes cardiac surgeons is often necessary. Long-term follow-up is important for all forms of heart inflammation to monitor for recurrence, chronic complications, and recovery of heart function.

Treatment of Pericarditis

Most cases of acute pericarditis can be managed on an outpatient basis with anti-inflammatory medications. The standard first-line treatment combines:

• NSAIDs (Non-steroidal anti-inflammatory drugs): Ibuprofen (600-800mg three times daily) or aspirin (750-1000mg three times daily) for 1-2 weeks with gradual tapering. NSAIDs reduce inflammation and relieve pain.
• Colchicine: 0.5mg once or twice daily for 3 months. Colchicine significantly reduces the risk of recurrence by approximately 50% and is now considered essential first-line therapy.
• Gastroprotection: Proton pump inhibitors are often prescribed to protect the stomach during NSAID therapy.

Corticosteroids are generally avoided as first-line therapy because they increase the risk of recurrence. However, they may be used when NSAIDs are contraindicated (such as in patients with kidney disease or bleeding disorders), in autoimmune pericarditis, or in refractory cases.

For pericarditis with large effusions or cardiac tamponade, pericardiocentesis (drainage of fluid using a needle) may be necessary. Recurrent pericarditis affects 15-30% of patients and may require prolonged colchicine therapy, immunosuppressive medications, or rarely, surgical removal of the pericardium (pericardiectomy).

Treatment of Myocarditis

Myocarditis treatment is primarily supportive, focusing on managing symptoms and preventing complications while the inflammation resolves. Key components include:

• Rest and activity restriction: This is perhaps the most important aspect of treatment. Physical exertion during active myocarditis can trigger dangerous arrhythmias and worsen heart damage. Athletes should avoid competitive sports for 3-6 months minimum.
• Heart failure medications: If heart function is reduced, standard heart failure medications including ACE inhibitors/ARBs, beta-blockers, and diuretics may be prescribed.
• Arrhythmia management: Antiarrhythmic medications or monitoring may be necessary for patients with significant rhythm disturbances.
• Immunosuppression: Reserved for specific forms like giant cell myocarditis or eosinophilic myocarditis, where suppressing the immune response is beneficial.

Patients with severe myocarditis causing cardiogenic shock may require intensive care with inotropic medications (drugs that strengthen heart contractions), mechanical circulatory support devices (such as ECMO or ventricular assist devices), or in extreme cases, heart transplantation.

Treatment of Endocarditis

Infective endocarditis requires aggressive treatment with prolonged intravenous antibiotics, typically for 4-6 weeks. The specific antibiotic regimen depends on the causative organism identified through blood cultures:

• Empiric therapy: Broad-spectrum antibiotics are started immediately after blood cultures are obtained, then adjusted based on culture results.
• Targeted therapy: Once the organism is identified, antibiotics are chosen for optimal effectiveness against that specific bacteria.
• Duration: Most patients require 4-6 weeks of intravenous antibiotics. Some may complete treatment at home with home IV therapy after initial hospitalization.

Surgery is required in approximately 25-30% of endocarditis cases. Indications for surgery include heart failure from severe valve damage, uncontrolled infection despite appropriate antibiotics, large vegetations with high embolic risk, abscess formation, and certain resistant organisms.

What Are the Complications of Heart Inflammation?

Complications include heart failure, cardiac arrhythmias (irregular heartbeats), cardiac tamponade (fluid compressing the heart), stroke or organ damage from emboli (in endocarditis), and sudden cardiac death. Dilated cardiomyopathy can develop as a long-term consequence of myocarditis. Early treatment significantly reduces complication risks.

Heart inflammation can lead to various complications depending on the type and severity of the condition. Understanding these potential complications helps patients recognize warning signs and emphasizes the importance of appropriate treatment and follow-up. While most patients recover without lasting effects, some develop chronic problems requiring ongoing management.

Heart Failure

Heart failure occurs when the heart cannot pump blood efficiently enough to meet the body's needs. In myocarditis, inflammation and damage to the heart muscle can weaken its pumping ability. Approximately 10-20% of myocarditis cases progress to dilated cardiomyopathy, a condition where the heart chambers enlarge and weaken. This can cause persistent symptoms of fatigue, shortness of breath, and fluid retention, requiring lifelong medications or even heart transplantation in severe cases.

In endocarditis, heart failure typically results from valve destruction by the infection. Severe valve regurgitation (backward leaking) causes volume overload and heart failure. This is one of the primary indications for urgent surgical intervention.

Cardiac Arrhythmias

Inflammation of the heart muscle can disrupt the electrical conduction system, leading to various arrhythmias. These can range from benign extra beats to life-threatening ventricular tachycardia or ventricular fibrillation. Arrhythmias are a major cause of sudden cardiac death in patients with myocarditis, which is why activity restriction is so crucial during the acute phase.

Some patients develop conduction abnormalities (heart blocks) that may require permanent pacemaker implantation. Long-term arrhythmia risk depends on the extent of scarring and residual heart damage after the acute inflammation resolves.

Cardiac Tamponade

Cardiac tamponade is a life-threatening complication of pericarditis where fluid accumulates rapidly in the pericardial space, compressing the heart and preventing it from filling properly. This causes a dramatic drop in blood pressure and can be fatal without emergency treatment. Signs include distended neck veins, low blood pressure, muffled heart sounds, and shortness of breath. Treatment requires urgent pericardiocentesis (needle drainage of fluid).

Embolic Complications

In endocarditis, vegetations on the heart valves can break off and travel through the bloodstream, causing blockages in various organs. The most devastating embolic complication is stroke, which occurs in 20-40% of patients with left-sided endocarditis. Other embolic complications include kidney infarction, splenic infarction, and infections spreading to other organs (septic emboli). Large vegetation size (greater than 10mm) increases embolic risk and may indicate the need for surgery.

What Is the Recovery Process and Prognosis?

Recovery varies widely: most pericarditis cases resolve within 2-4 weeks with appropriate treatment. Myocarditis recovery takes longer - approximately 50% of patients recover completely, while others may have residual heart dysfunction. Athletes typically need 3-6 months before returning to sports. Regular follow-up with repeat imaging helps monitor recovery.

The prognosis for heart inflammation depends on multiple factors including the type of inflammation, underlying cause, severity, promptness of treatment, and the patient's overall health. While many patients make full recoveries, others face long-term consequences requiring ongoing medical care.

Recovery from Pericarditis

Acute viral pericarditis typically resolves within 2-4 weeks with appropriate treatment. Most patients respond well to NSAIDs and colchicine, with symptoms improving within the first few days of treatment. The most significant challenge is recurrence, which affects 15-30% of patients. Recurrent episodes may become less frequent and less severe over time, and most patients eventually achieve lasting remission.

Constrictive pericarditis, a rare chronic complication where the pericardium becomes thickened and rigid, can develop months to years after acute pericarditis. This serious condition causes heart failure symptoms and may require surgical pericardiectomy.

Recovery from Myocarditis

Myocarditis outcomes are more variable. Studies suggest approximately 50% of patients recover completely with normalization of heart function. About 25% develop persistent mild heart dysfunction, and approximately 25% progress to more significant dilated cardiomyopathy or heart failure.

Factors associated with better prognosis include:

• Milder initial presentation
• Preserved heart function at diagnosis
• Viral cause (especially parvovirus B19)
• Absence of late gadolinium enhancement on MRI
• Improvement in heart function at early follow-up

Giant cell myocarditis and cardiac sarcoidosis have worse prognoses than viral myocarditis and often require aggressive immunosuppression and sometimes mechanical support or transplantation.

Return to Activities and Sports

Activity restriction is crucial during recovery from myocarditis. Current guidelines recommend:

• Minimum 3-6 months of competitive sports restriction after acute myocarditis
• Complete resolution of symptoms before considering return to exercise
• Normal or near-normal heart function on echocardiogram
• No significant arrhythmias on Holter monitoring or exercise testing
• No residual inflammation on repeat cardiac MRI when feasible

Gradual return to activity should be supervised by a cardiologist familiar with sports cardiology. The risk of sudden cardiac death during exercise decreases as the acute inflammation resolves and the heart heals.

How Can Heart Inflammation Be Prevented?

Prevention strategies include good hand hygiene to avoid viral infections, vaccination against influenza and COVID-19, maintaining good dental hygiene (for endocarditis prevention), taking prescribed antibiotic prophylaxis before dental procedures (for high-risk patients), and avoiding intravenous drug use. Prompt treatment of infections may reduce the risk of cardiac complications.

While not all cases of heart inflammation can be prevented, certain measures can reduce risk. Prevention strategies focus on avoiding the infections and conditions that cause heart inflammation, as well as specific prophylaxis for those at high risk of endocarditis.

Infection Prevention

Since viral infections are the most common cause of myocarditis and pericarditis, standard infection prevention measures are important:

• Hand hygiene: Regular handwashing helps prevent transmission of respiratory and gastrointestinal viruses
• Vaccination: Stay up-to-date with recommended vaccines, including influenza and COVID-19 vaccines
• Avoid close contact with sick individuals: Particularly during cold and flu season
• Prompt treatment of infections: Seeking medical care for persistent or severe infections may reduce the risk of cardiac complications

Endocarditis Prevention

For patients at high risk of endocarditis (those with prosthetic heart valves, previous endocarditis, certain congenital heart defects, or cardiac transplant recipients with valve problems), specific prevention measures are recommended:

• Antibiotic prophylaxis: Before dental procedures involving the gums or dental root area
• Good dental hygiene: Regular brushing, flossing, and dental check-ups reduce bacteremia (bacteria in the blood) from oral sources
• Avoid body piercing and tattoos: Or ensure sterile technique if performed
• Prompt treatment of skin infections: To prevent bacterial entry into the bloodstream
• Avoid intravenous drug use: A major risk factor for endocarditis