Predicting the occurrence of embolic events: an analysis of 1456 episodes of infective endocarditis from the Italian Study on Endocarditis (SEI)

Abstract

BackgroundEmbolic events are a major cause of morbidity and mortality in patients with infective endocarditis. We analyzed the database of the prospective cohort study SEI in order to identify factors associated with the occurrence of embolic events and to develop a scoring system for the assessment of the risk of embolism.MethodsWe retrospectively analyzed 1456 episodes of infective endocarditis from the multicenter study SEI. Predictors of embolism were identified. Risk factors identified at multivariate analysis as predictive of embolism in left-sided endocarditis, were used for the development of a risk score: 1 point was assigned to each risk factor (total risk score range: minimum 0 points; maximum 2 points). Three categories were defined by the score: low (0 points), intermediate (1 point), or high risk (2 points); the probability of embolic events per risk category was calculated for each day on treatment (day 0 through day 30).ResultsThere were 499 episodes of infective endocarditis (34%) that were complicated by ≥ 1 embolic event. Most embolic events occurred early in the clinical course (first week of therapy: 15.5 episodes per 1000 patient days; second week: 3.7 episodes per 1000 patient days). In the total cohort, the factors associated with the occurrence of embolism at multivariate analysis were prosthetic valve localization (odds ratio, 1.84), right-sided endocarditis (odds ratio, 3.93), Staphylococcus aureus etiology (odds ratio, 2.23) and vegetation size ≥ 13 mm (odds ratio, 1.86). In left-sided endocarditis, Staphylococcus aureus etiology (odds ratio, 2.1) and vegetation size ≥ 13 mm (odds ratio, 2.1) were independently associated with embolic events; the 30-day cumulative incidence of embolism varied with risk score category (low risk, 12%; intermediate risk, 25%; high risk, 38%; p < 0.001).ConclusionsStaphylococcus aureus etiology and vegetation size are associated with an increased risk of embolism. In left-sided endocarditis, a simple scoring system, which combines etiology and vegetation size with time on antimicrobials, might contribute to a better assessment of the risk of embolism, and to a more individualized analysis of indications and contraindications for early surgery.

Infective endocarditis in elderly: An Italian prospective multi-center observational study

“…These changes have important implications for the modern management of IE [2]. Several international and Italian studies have shown an increase in elderly and chronically ill patients with IE [1,[3][4][5][6][7].…”

Clinical manifestations of infective endocarditis in relation to infectious agents: An 8-year retrospective study

“…In our study, the relationship between the length of vegetation and systemic embolism was not observed, but we did prove that high mobility of vegetation is an independent risk factor of embolism, which is in line with the most recently published data 18,20,24 . Two simple calculator systems for predicting embolic risk upon admission of patients with IE have been recently designed; one French 25 and one Italian 26 . Both include S. aureus infection as an excellent predictor of embolic risk.…”

Haemophilus parainfluenzaeMural Endocarditis: Case Report and Review of the Literature

“…The risk of embolization is associated with large vegetation size and hyphal morphology of vegetations in Haemophilus endocarditis [8]. In a study of all cause endocarditis, vegetations greater than 10 mm exhibited 2.8 greater odds of embolization [9]. More than half of patients with Haemophilus parainfluenzae endocarditis have no predisposing valvular disease, although congenital and iatrogenic abnormalities of the myocardium are common as among all cases of endocarditis [8].…”