Analysis of sex differences in the clinical presentation, management and prognosis of infective endocarditis in Spain

Abstract

IntroductionSex-dependent differences of infective endocarditis (IE) have been reported. Women suffer from IE less frequently than men and tend to present more severe manifestations. Our objective was to analyse the sex-based differences of IE in the clinical presentation, treatment, and prognosis.Material and methodsWe analysed the sex differences in the clinical presentation, modality of treatment and prognosis of IE in a national-level multicentric cohort between 2008 and 2018. All data were prospectively recorded by the GAMES cohort (Spanish Collaboration on Endocarditis).ResultsA total of 3451 patients were included, of whom 1105 were women (32.0%). Women were older than men (mean age, 68.4 vs 64.5). The most frequently affected valves were the aortic valve in men (50.6%) and mitral valve in women (48.7%). Staphylococcus aureus aetiology was more frequent in women (30.1% vs 23.1%; p<0.001).Surgery was performed in 38.3% of women and 50% of men. After propensity score (PS) matching for age and estimated surgical risk (European System for Cardiac Operative Risk Evaluation II (EuroSCORE II)), the analysis of the matched cohorts revealed that women were less likely to undergo surgery (OR 0.74; 95% CI 0.59 to 0.91; p=0.05).The observed overall in-hospital mortality was 32.8% in women and 25.7% in men (OR for the mortality of female sex 1.41; 95% CI 1.21 to 1.65; p<0.001). This statistical difference was not modified after adjusting for all possible confounders.ConclusionsFemale sex was an independent factor related to mortality after adjusting for confounders. In addition, women were less frequently referred for surgical treatment.

Sex-Specific Risk Factors for Short- and Long-Term Outcomes after Surgery in Patients with Infective Endocarditis

“…The overall early mortality of 17.9% in our study was comparable to the 17% mortality reported in the European endocarditis registry [ 3 ] and 17.2% mortality after surgery for IE of the aortic valve [ 12 ]. Women in our study experienced a significantly higher early mortality when compared to men as demonstrated previously [ 12 , 13 , 17 ]. However, in contrast to these studies, we found no major sex-specific differences regarding baseline clinical presentation, comorbidities, or pathogenic organisms that could explain the poorer outcome in women, but rather a gender-specific impact of risk factors, as the univariate and multivariable analysis indicated.…”

“…The proportion of our surgically treated female patients was 25.4%, which is lower than 31.1% in the European infective endocarditis registry, which also included non-surgically treated patients [ 3 ]. This points to an underlying lower rate of referral to cardiac surgery in our female patients, a finding already described in several recent studies [ 3 , 9 , 13 , 15 ].…”

“…In contrast to previous findings [ 8 , 9 , 12 , 14 ], female patients in our study were not distinctly older and did not present with more comorbid conditions when compared to men. As shown in previous studies [ 9 , 13 , 17 ], IE affected the aortic valve in men most frequently, while in female patients, a predominant affection of the mitral valve was found.…”

“…Despite major medical advances in diagnostics and therapy, IE is still associated with severe morbidity and a high early mortality of around 20% [ 3 , 10 , 11 ]. In cases of IE, female gender shows no protective effect, since several studies demonstrate a similar or higher early mortality when compared to men [ 8 , 12 , 13 , 14 , 15 ]. The persistently poor overall prognosis regarding hospital mortality is, besides the female gender, attributed to several possible causative factors such as the increase of elderly and more severely ill patients, previous cardiac surgery, an increasing rate of IE in prosthetic heart valves and devices, cerebral complications, renal failure, preoperative ventilation, New York Heart Association heart failure (NYHA) stage, paravalvular abscess, S. aureus infection, and withholding of indicated surgery [ 3 , 10 , 12 , 16 ].…”

“…The persistently poor overall prognosis regarding hospital mortality is, besides the female gender, attributed to several possible causative factors such as the increase of elderly and more severely ill patients, previous cardiac surgery, an increasing rate of IE in prosthetic heart valves and devices, cerebral complications, renal failure, preoperative ventilation, New York Heart Association heart failure (NYHA) stage, paravalvular abscess, S. aureus infection, and withholding of indicated surgery [ 3 , 10 , 12 , 16 ]. However, there are controversial implications if the female gender is an independent predictor for mortality after surgery for IE [ 4 , 13 , 16 , 17 ]. Older age, a different spectrum of comorbidities, and a lower rate of surgical treatment are discussed as risk factors for a poorer outcome in women [ 8 , 9 , 12 ].…”