Background
Methods
Patients
Clinical data
Statistical analysis
Results
Clinical characteristics of patients and embolic events
Characteristics | All episodes | LS-NVE | LS-PVE | RS-IE | CIED-IE |
---|---|---|---|---|---|
Number of IE episodes | 1456 (100) | 967 (66.4) | 339 (23.3) | 89 (6.1) | 61 (4.2) |
Age (y) | 65 (50 to 64) | 64 (48 to 74) | 70 (61 to 76) | 48 (35 to 67) | 67 (55 to 77) |
Male | 1018 (70) | 688 (71) | 221 (65) | 61 (69) | 48 (79) |
Comorbidity and predisposing conditions | |||||
Native valve disease | 372 (26) | 299 (31) | 60 (18) | 7 (8) | 6 (10) |
Diabetes mellitus | 268 (18) | 164 (17) | 79 (23) | 10 (11) | 15 (25) |
Chronic liver disease | 262 (18) | 169 (18) | 49 (15) | 38 (43) | 6 (10) |
Cancer | 175 (12) | 131 (14) | 28 (8) | 10 (11) | 6 (10) |
Chronic intravenous access | 154 (11) | 102 (11) | 34 (10) | 11 (12) | 7 (12) |
Current intravenous drug abuse | 131 (9) | 81 (8) | 14 (4) | 34 (38) | 2 (3) |
Previous IE | 118 (8) | 48 (5) | 59 (17) | 7 (8) | 4 (7) |
Congenital heart disease | 112 (8) | 85 (9) | 16 (5) | 6 (7) | 5 (8) |
Immunosuppressive therapy | 86 (6) | 70 (7) | 11 (3) | 2 (2) | 3 (5) |
HIV infection | 52 (4) | 36 (4) | 4 (1) | 10 (11) | 2 (3) |
Hemodialysis | 29 (2) | 21 (2) | 4 (1) | 2 (2) | 2 (3) |
Microbiology | |||||
Staphylococcus aureus
| 283 (19) | 181 (19) | 53 (16) | 35 (39) | 14 (23) |
Viridans group streptococci | 217 (15) | 172 (18) | 29 (9) | 8 (9) | 8 (13) |
Enterococcus species | 182 (13) | 117 (12) | 53 (16) | 8 (9) | 4 (7) |
Coagulase-negative staphylococci | 147 (10) | 74 (8) | 55 (16) | 4 (5) | 14 (23) |
Streptococcus bovis
| 142 (10) | 105 (11) | 29 (9) | 7 (8) | 1 (2) |
Other streptococci | 59 (4) | 46 (5) | 7 (2) | 3 (3) | 3 (5) |
Other microorganisms | 61 (4) | 36 (4) | 20 (6) | 2 (2) | 3 (5) |
Polymicrobial | 51 (4) | 34 (4) | 10 (3) | 4 (5) | 3 (5) |
Fungi | 20 (1) | 12 (1) | 8 (2) | 0 (0) | 0 (0) |
HACEK | 3 (0.2) | 0 (0) | 2 (0.6) | 1 (1) | 0 (0) |
Microbiology negative | 291 (20) | 190 (20) | 73 (22) | 17 (19) | 11 (18) |
Characteristics | All IE episodes | LS-NVE | LS-PVE | RS-IE | CIED-IE |
---|---|---|---|---|---|
Number of IE episodes | 1456 | 967 | 339 | 89 | 61 |
Embolic events | 700 | 436 | 166 | 74 | 24 |
CNS emboli | 249 (36) | 174 (40) | 68 (41) | 3 (4) | 4 (17) |
Ischemic stroke | 176 (25) | 126 (29) | 45 (27) | 2 (3) | 3 (13) |
Transient ischemic attack | 42 (6) | 26 (6) | 14 (8) | 1 (1) | 1 (4) |
Hemorrhagic stroke | 31 (4) | 22 (5) | 9 (6) | 0 (0) | 0 (0) |
Peripheral emboli | 451 (64) | 262 (60) | 98 (59) | 71 (96) | 20 (83) |
Pulmonary | 122 (17) | 26 (6) | 25 (15) | 57 (84) | 14 (58) |
Splenic | 117 (17) | 90 (21) | 23 (14) | 3 (4) | 1 (4) |
Limbs | 95 (14) | 70 (16) | 15 (9) | 7 (10) | 3 (13) |
Other | 117 (17) | 76 (17) | 35 (21) | 4 (6) | 2 (8) |
Factors associated with embolic events
Characteristics | IE episodes | IE episodes |
p ≤ † |
---|---|---|---|
with embolic | without embolic | ||
events | events | ||
Number of episodes of IE | 499 | 957 | |
Age (y)
|
62 (28 to 81)
|
67 (31 to 84)
|
0.0002
|
Male | 361 (72) | 657 (69) | NS |
Hemodialysis | 10 (2) | 19 (2) | NS |
Diabetes mellitus | 86 (17) | 182 (19) | NS |
HIV infection
|
29 (6)
|
23 (2)
|
0.004
|
Cancer
|
46 (9)
|
129 (13)
|
0.03
|
Chronic liver disease
|
115 (23)
|
147 (15)
|
0.0005
|
Current intravenous drug abuse
|
74 (15)
|
57 (6)
|
0.0001
|
Previous IE | 38 (8) | 80 (8) | NS |
Chronic intravenous access | 59 (12) | 95 (10) | NS |
Congenital heart disease | 38 (8) | 74 (8) | NS |
Native valve predisposition | 132 (26) | 270 (28) | NS |
Nosocomial IE | 29 (6) | 50 (5) | NS |
Health care associated IE | 107 (21) | 227 (24) | NS |
Community-acquired IE | 363 (73) | 680 (71) | NS |
Native vs prosthetic valve | 385 vs 114 | 732 vs 225 | NS |
Site of IE (n = 1282) | |||
Mitral vs aortic valve | 166 vs 161 | 329 vs 359 | NS |
Bivalvular involvement (mitral and aortic) | 39 (8) | 78 (8) | NS |
Right-sided IE
|
60 (12)
|
29 (3)
|
0.0001
|
CIED-IE | 21 (4) | 40 (4) | NS |
Vegetations (n = 710)‡ | |||
Size of all vegetations (mm)
|
14 (6 to 30)
|
10 (4 to 26)
|
0.0001
|
≥ 10 mm
|
228 (79)
|
264 (63)
|
0.0001
|
≥ 15 mm
|
142 (49)
|
145 (35)
|
0.0001
|
≥ 20 mm
|
74 (26)
|
78 (19)
|
0.03
|
Concomitant therapy at onset of IE | |||
Anticoagulants | 102 (20) | 228 (24) | NS |
Antiaggregants | 68 (14) | 103 (11) | NS |
Microbiology | |||
Staphylococcus aureus
|
141 (28)
|
142 (15)
|
0.0001
|
Viridans group streptococci | 66 (13) | 151 (16) | NS |
Coagulase-negative staphylococci | 52 (10) | 95 (10) | NS |
Enterococcus
species
|
45 (9)
|
137 (1)
|
0.004
|
Streptococcus bovis
| 44 (9) | 98 (10) | NS |
Polymicrobial | 19 (4) | 32 (3) | NS |
Other microorganisms | 16 (3) | 45 (6) | NS |
Other streptococci | 16 (3) | 43 (5) | NS |
Fungi/yeasts | 7 (1) | 13 (1) | NS |
HACEK | 1 (0.2) | 2 (0.2) | NS |
Microbiology negative | 92 (18) | 199 (21) | NS |
Odds ratio | 95% CI | p ≤ † | |
---|---|---|---|
Age | 1.0 | 1.0 – 1.0 | NS |
HIV infection | 0.8 | 0.3 – 2.0 | NS |
Cancer | 1.10 | 0.7 – 1.9 | NS |
Chronic liver disease | 1.4 | 0.9 – 2.2 | NS |
Mitral vs aortic valve | 1.0 | 0.7 – 1.3 | NS |
Prosthetic vs native valve
|
1.8
|
1.2 – 2.9
|
0.011
|
Righ-sided IE
|
3.9
|
2.0 – 7.7
|
<0.0001
|
Size of vegetation ≥ 13 mm
|
1.9
|
1.3 – 2.6
|
<0.0001
|
Staphylococcus aureus
|
2.2
|
1.5 – 3.4
|
<0.0001
|
Coagulase-negative staphylococci
| 1.6 | 1.0 – 2.6 | NS |
Enterococcus spp. | 0.8 | 0.4 – 1.4 | NS |
Anticoagulant therapy | 0.8 | 0.5 – 1.3 | NS |
Risk score
-
low risk category (no poor prognostic factor: etiology other than S. aureus, and vegetations size <13 mm);
-
intermediate risk category (1 poor prognostic factor: S. aureus etiology or vegetations size ≥ 13 mm);
-
high risk category (2 poor prognostic factors: S. aureus etiology and vegetations size ≥ 13 mm).
-
The 30-day cumulative incidence of embolism varied significantly across the different risk categories: 11.8% (95% CI 7.2 – 19.2) in the low risk category, 24.5% (95% CI 20.3 – 37.0) in the intermediate risk category, 37.7 (95% CI 22.1 – 64.9) in the high risk category. Kaplan-Meier plots showed that the 3 risk categories differed significantly from each other by log-rank test and test for trend (p ≤ 0.001) (Figure 3, Table 5).
Time from start of therapy (d) | Low (0) |
Intermediate(1) |
High(2) |
---|---|---|---|
0 | 11.78 | 24.54 | 37.73 |
1 | 7.90 | 20.82 | 34.79 |
2 | 6.61 | 18.95 | 25.97 |
3 | 4.88 | 16.13 | 25.97 |
4 | 4.01 | 14.70 | 25.97 |
5 | 4.01 | 12.78 | 25.97 |
6 | 3.14 | 11.34 | 25.97 |
7 | 2.71 | 8.95 | 22.81 |
15 | 0.48 | 5.02 | 3.46 |
30 | 0.00 | 0.00 | 0.00 |