It is not how old you are, it is how you are old: need for changes in the management of infective endocarditis in the elderly

The world’s population is ageing at an expedited rate. By the end of the century, a person is expected to live for 81 years in low/middle-income countries and 89 years in high-income countries where persons 85 years and older are now the fastest growing part of the population.1 The elderly population has clearly benefited from medical progress; degenerative heart diseases are now often treated by means of less invasive techniques with reduced procedural risks and increased survival. However, the increased number of cardiac valvar and non-valvar intracardiac devices and procedures in addition to impaired function of the immune system (the so-called immunosenescence), increased functional limitations and more frequent comorbidities make elderly patients more prone to infective endocarditis (IE). IE in the elderly represents a major challenge because of atypical clinical presentation, different epidemiology, high frequency and lethality. Clinical case series consistently described that older patients with IE have a higher mortality, are less likely to have surgery and more likely to have prosthetic devices, and be infected with bacteria entering the bloodstream through colonic neoplasms (such as group D Streptococcus ) or through the urinary tract (such as Enterococcus spp), given the higher proportion of chronic urinary infection or urethral and prostatic procedures. Older people have smaller vegetations and less embolic manifestations, while confusion is a prominent clinical feature.2–4 However, older age is an ill-defined entity. Most published studies focused on patients over 65 years, while few papers have evaluated IE among octogenarians. Oliver et al in this issue of Heart present the clinical and microbiological characteristics of IE in the very old (ie, >80 years) patients and compared with old (65 to 80 years) and adult (<65 years) population.5 There were some peculiar aspects of IE in the oldest group: Enterococci and S treptococcus gallolyticus were the more frequent causative agents, embolism under …