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Vol. 68. Núm. 5.
Páginas 445-448 (Mayo 2015)
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Vol. 68. Núm. 5.
Páginas 445-448 (Mayo 2015)
Scientific Letter
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Changes in Clinical Profile, Epidemiology and Prognosis of Left-sided Native-valve Infective Endocarditis Without Predisposing Heart Conditions
Cambios en el perfil clínico, epidemiológico y pronóstico de la endocarditis infecciosa nativa izquierda sin lesión cardiaca predisponente
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Francisco J. Castillo, Manuel Anguita
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, Juan C. Castillo, Martín Ruiz, Dolores Mesa, José Suárez de Lezo
Servicio de Cardiología, Hospital Universitario Reina Sofía, Córdoba, Spain
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Tablas (2)
Table 1. Comparative Characteristics Between Left-sided Native-valve Endocarditis With and Without Underlying Heart Disease (n=240)
Table 2. Comparison of the Characteristics of the Subgroup of Patients With Endocarditis Without Underlying Heart Disease Between the Periods 1987 to 2000 and 2001 to 2013 (n=104)
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To the Editor,

Traditionally, infective endocarditis (IE) has been considered as a disease affecting patients with underlying heart disease (HD).1 This profile appears to have changed in recent decades, in that EI affects both patients with degenerative valve disease and those with no apparent HD.1–4 Various studies have shown that the proportion of patients with IE and no underlying HD has increased in our setting.2,5,6 Although each type of IE appears to have distinct epidemiologic and prognostic characteristics,2,5 it is not known whether the profile of non-HDIE has changed in recent years, which could have implications for prognosis. The objectives of our study were: a) to compare the characteristics of HD-associated left-sided native-valve IE (HDIE) and non-HD-associated left-sided native-valve IE (non-HDIE) diagnosed at our center between 1987 and 2013, and b) to study changes in the profile of non-HDIE during this period.

We analyzed a series of 420 consecutive patients diagnosed with IE between 1987 and 2013, of which 240 (57%) had left-sided native-valve IE. Diagnosis was made according to the Von Reyn, Duke and modified Duke criteria, depending on the time period. The management protocol did not change over this period, except for the introduction of transesophageal echocardiography during the 1990s. Each patient was classified as having either HDIE or non-HDIE, depending on the results of transthoracic and transesophageal echocardiography during the episode of IE, previous echocardiograms, medical history, and surgical and autopsy findings. The valve was considered normal when the portions of the leaflets that were unaffected by infection were normal and there was no chordal involvement or commissural fusion.5 The active phase of the disease was defined as the first 6 weeks from symptom onset. Urgent surgery was defined as that which could not be postponed for more than 24hours without risk to the patient's life, while elective surgery was defined as that carried out after 24hours.

Of the 240 cases of left native-valve IE, 104 (43%) were classified as non-HDIE, and the remaining 136 (57%) were diagnosed with HDIE. The proportion of cases of non-HDIE increased significantly, constituting 25.7% of cases of left-sided native-vale IE from 1987 to 2000 and 56.1% from 2001 to 2013 (P<.001). The characteristics of both types of patients during the entire 27-year period are shown in Table 1. The rate of serious complications, premature mortality, and need for surgery were similar, whereas there were significant differences in epidemiological characteristics: patients with non-HDIE had a higher prevalence of non-cardiac risk factors and predisposing comorbidities (chronic gastrointestinal diseases, malignancies, renal failure, diabetes, immunosuppression) and healthcare-related procedures (intravascular catheters, and nosocomial and nosohusial EI), but less frequently had IE caused by Streptococcus viridans (Table 1). The characteristics of patients with non-HDIE from 1987 to 2000 and from 2001 to 2013 are shown in Table 2, highlighting significant changes in both the clinical and epidemiological profile between the 2 periods. In the most recent period, patients with non-HDIE were much older (almost 20 years older, on average), had larger vegetations, a tendency to have IE caused less by Staphylococcus aureus and more by Streptococcus viridans, and a higher prevalence of non-cardiac risk factors for IE, and more frequently had IE associated with health care procedures. The incidence of serious complications during the active phase of IE, especially of heart failure/valve dysfunction and persistent sepsis, was also significantly higher during the most recent period. Early mortality more than doubled in the second period (35.9% vs 15.4%; P=.043), as did the need for early surgery (69.2% vs 34.6%; P=.002) (Table 2).

Table 1.

Comparative Characteristics Between Left-sided Native-valve Endocarditis With and Without Underlying Heart Disease (n=240)

  Non-HDIE (n=104)  HDIE (n=136)  P 
Age, y  55.93 (18.73)  52.34 (18.62)  .167 
Sex, male  68 (65.4)  99 (72.8)  .216 
Previous endocarditis  1 (0.9)  2 (1.5)  .975 
Infection site      .094 
Mitral  58 (55.8)  61 (44.9)   
Aortic  46 (43.3)  753 (55.1)   
Vegetations on transthoracic echocardiography  84 (80.7)  103 (75.7)  .181 
Vegetations on transesophageal echocardiography  80 (98.8)  105 (99.1)  .946 
Vegetation size, mm  13.13 (4.37)  11.70 (4.23)  .025 
Epidemiological characteristics
Entry site
Dental  5 (4.8)  17 (12.5)  .041 
Respiratory  1 (0.9)  1 (0.7)  .968 
Gastrointestinal  7 (6.8)  8 (5.9)  .788 
Genitourinary  5 (4.8)  6 (4.4)  .935 
Vascular catheter  13 (12.5)  2 (1.4)  <.001 
Unknown  73 (70.2)  102 (75.0)  .869 
Bacterium
Staphylococcus aureus  21 (20.2)  24 (17.8)  .610 
Staphylococcus epidermidis  8 (7.7)  13 (9.6)  .616 
Streptococcus viridans  18 (17.3)  48 (35.6)  .002 
Enterococci  24 (23.1)  20 (14.8)  .135 
Others  14 (13.3)  11 (8.1)  .385 
Unidentified  20 (14.1)  17 (12.5)  .203 
Risk factors  50 (48.1)  21 (15.4)  <.001 
Intravascular catheter  13 (12.5)  2 (1.4)  <.001 
Renal failure  10 (9.6)  10 (7.3)  .573 
Gastrointestinal disorders  17 (16.1)  5 (4.8)  .025 
Immunocompromised  9 (8.6)  1 (0.7)  .040 
Neoplasms  10 (9.5)  3 (2.2)  .035 
Diabetes mellitus  8 (7.6)  2 (1.4)  .063 
Indwelling urinary catheter  3 (2.8)  0 (0.0)  .266 
Endocarditis related to healthcare  38 (36.1)  13 (9.6)  <.001 
Nosocomial  10 (9.5)  1 (0.7)  .042 
Nosohusial  28 (26.6)  12 (8.8)  .035 
Complications, mortality, and surgery
Development of complications  87 (83.6)  103 (76.3)  .143 
Complications in the acute phase
Heart failure/valve dysfunction  66 (63.4)  74 (54.4)  .159 
Embolism  21 (20.2)  34 (25.0)  .380 
Neurological  25 (24)  25 (18.4)  .285 
Persistent sepsis  24 (23.1)  21 (15.4)  .133 
Acute renal failure  10 (9.6)  8 (5.9)  .277 
Intracardiac abscess  18 (17.5)  22 (16.2)  .790 
Surgery during the active phase
Urgent  20 (19.2)  29 (21.3)  .714 
Elective  43 (41.3)  53 (39.0)  .697 
Total  63 (60.5)  82 (60.3)  .985 
Early mortality  32 (30.8)  30 (22.1)  .172 

HDEI, heart disease-associated infective endocarditis; non-HDIE, non-heart disease-associated infective endocarditis.

Data are expressed as mean (standard deviation).

Table 2.

Comparison of the Characteristics of the Subgroup of Patients With Endocarditis Without Underlying Heart Disease Between the Periods 1987 to 2000 and 2001 to 2013 (n=104)

  1987-2000 (n=26)  2001-2013 (n=78)  P 
Age, y  41.54 (21.11)  60.42 (15.22)  <.001 
Sex, male  19 (73.1)  49 (62.8)  .341 
Previous endocarditis  0 (0)  1 (1.3) 
Infection site
Mitral  16 (61.5)  42 (53.8)  .494 
Aortic  10 (38.5)  36 (46.2)  .494 
Vegetations on transthoracic echocardiography  22 (84.6)  62 (81.6) 
Vegetations on transesophageal echocardiography  17 (100)  63 (98.4) 
Vegetation size, mm  10.68 (2.93)  13.98 (4.49)  .002 
Epidemiological characteristics
Entry site
Dental  0 (0)  5 (6.4)  .328 
Respiratory  0 (0)  1 (1.4) 
Gastrointestinal  2 (7.7)  5 (6.4) 
Genitourinary  0 (0)  5 (6.4)  .328 
Catheter  1 (3.8)  14 (17.9)  .035 
Unknown  23 (88.5)  48 (61.5)  .045 
Bacterium
Staphylococcus aureus  8 (30.8)  13 (16.9)  .129 
Staphylococcus epidermidis  1 (3.8)  7 (9.1)  .676 
Streptococcus viridans  2 (7.7)  16 (20.8)  .230 
Enterococci  7 (26.9)  16 (20.8)  .588 
Others  5 (19.2)  10 (13)  .521 
Negative blood culture  3 (11.5)  15 (19.5)  .551 
Risk factors  7 (26.9)  43 (55.1)  .003 
Intravascular catheter  1 (3.8)  12 (15.4)  .421 
Renal failure  2 (7.6)  8 (10.4)  .712 
Gastrointestinal disorders  3 (11.4)  14 (17.9)  .493 
Immunocompromised  1 (3.8)  8 (10.4)  .523 
Neoplasms  3 (11.4)  7 (9.1)  .322 
Diabetes mellitus  2 (7.6)  6 (7.7)  .845 
Indwelling urinary catheter  1 (3.8)  2 (2.6)  .566 
Endocarditis related to healthcare  6 (23.1)  32 (41.0)  .025 
Nosocomial  1 (3.8)  9 (10.5)  .679 
Nosohusial  5 (19.3)  23 (29.5)  .145 
Complications, mortality, and surgery
Serious complications  17 (65.4)  70 (90.9)  .004 
Type of complication
CHF/valve dysfunction  9 (34.6)  57 (73.1)  <.001 
Embolism  7 (26.9)  14 (17.9)  .324 
Neurological  5 (19.2)  20 (25.6)  .508 
Persistent sepsis  1 (3.8)  23 (29.5)  .007 
Acute renal failure  2 (7.7)  8 (10.3) 
Intracardiac abscess  4 (16)  14 (17.9) 
Surgery during the active phase
Urgent  5 (19.2)  15 (19.2) 
Elective  4 (15.4)  39 (50)  .002 
Total  9 (34.6)  54 (69.2)  .002 
Early mortality  4 (15.4)  28 (35.9)  .043 

CHF, chronic heart failure.

Data are expressed as mean (standard deviation).

Our data indicate that in our setting non-HDIE has shifted during the last 25 years toward a more serious clinical and prognostic profile (higher incidence of serious complications, need for surgery, and early mortality). This change may be because non-HDIE patients in the most recent period were much older and had a higher prevalence of severe comorbidities and non-cardiac risk factors for IE (chronic gastrointestinal and kidney diseases, immunosuppression, catheters and long-term vascular access). This type of IE now represents more than half of cases of native-valve IE,6 which may partly explain why the clinical characteristics, morbidity and mortality of non-HDIE are increasingly similar to those of HDIE, as shown in Table 1. This change also obliges us to change our attitude toward non-HDIE, which is no longer a more “benign” disease than HDIE. Infective endocarditis without predisposing HD should be suspected in the absence of predisposing cardiac disease to allow its early diagnosis and treatment, thus helping to reduce its increasing mortality.

References
[1]
N. Fernández-Hidalgo, P. Tornos.
Epidemiología de la endocarditis infecciosa en España en los últimos 20 años.
Rev Esp Cardiol., 66 (2013), pp. 728-733
[2]
J.C. Castillo, M. Anguita, M. Ruiz, L. Peña, M. Santisteban, M. Puentes, et al.
Cambios epidemiológicos de la endocarditis infecciosa sobre válvula nativa.
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[3]
N. Fernández-Hidalgo, B. Almirante, P. Tornos, M. González-Alujas, A. Planes, M. Galiñanes, et al.
Immediate and long-term outcome of left-sided infective endocarditis. A 12-year prospective study from a contemporary cohort in a referral hospital.
Clin Microbiol Infect., 18 (2012), pp. E522-E530
[4]
J. López, A. Revilla, I. Vilacosta, T. Sevilla, E. Villacorta, C. Sarriá, et al.
Age-dependent profile of left-sided infective endocarditis: a 3-center experience.
Circulation., 121 (2010), pp. 892-897
[5]
C. Olmos, I. Vilacosta, C. Fernández, C. Carriá, J. López, M. del Trigo, et al.
Comparison of clinical features of left-sided infective endocarditis involving previously normal versus previously abnormal valves.
Am J Cardiol., 114 (2014), pp. 278-283
[6]
F. Carrasco-Chinchilla, G. Sánchez-Espín, J. Ruiz-Morales, I. Rodríguez-Bailón, J.M. Melero-Tejedor, R. Ivanova-Georgieva, et al.
Influencia de una estrategia de alerta multidisciplinaria en la mortalidad por endocarditis infecciosa izquierda.
Rev Esp Cardiol., 67 (2014), pp. 380-386
Copyright © 2014. Sociedad Española de Cardiología
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