Temporal relationship between infective endocarditis and stroke

Abstract

Objective: Stroke frequently complicates infective endocarditis (IE). However, the temporal relationship between these diseases is uncertain.Methods: We performed a retrospective study of adult patients hospitalized for IE between July 1, 2007, and June 30, 2011, at nonfederal acute care hospitals in California. Previously validated diagnosis codes were used to identify the primary composite outcome of ischemic or hemorrhagic stroke during discrete 1-month periods from 6 months before to 6 months after the diagnosis of IE. The odds of stroke in these periods were compared with the odds of stroke in the corresponding 1-month period 2 years earlier, which was considered the baseline risk of stroke.Results: Among 17,926 patients with IE, 2,275 strokes occurred within the 12-month period surrounding the diagnosis of IE. The risk of stroke was highest in the month after diagnosis of IE (1,640 vs 17 strokes in the corresponding month 2 years prior). This equaled an absolute risk increase of 9.1% (95% confidence interval 8.6%-9.5%) and an odds ratio of 96.5 (95% confidence interval 60.1-166.0). Stroke risk was significantly increased beginning 4 months before the diagnosis of IE and lasting 5 months afterward. Similar temporal patterns were seen when ischemic and hemorrhagic strokes were considered separately. Conclusions:The association between IE and stroke persists for longer than previously reported.Most diagnoses of stroke and IE are made close together in time, but a period of heightened stroke risk becomes apparent several months before the diagnosis of IE and lasts for several months afterward. Infective endocarditis (IE) occurs in 1.7 to 6.2 per 100,000 people per year in the United States and Europe.1 Stroke often complicates IE, affecting approximately 16% to 25% of patients with IE.2,3 Cerebral embolism heralding or following a diagnosis of IE substantially increases morbidity and mortality.3-5 However, knowledge is limited regarding the time period during which patients with IE face a heightened stroke risk, with reports ranging from as early as 40 days before IE is recognized to as late as 5 weeks after the start of antibiotic treatment.3,4,6-8 Recent data suggest that IE may increase stroke risk for even longer periods of time, as one European cohort study reported that patients had a moderately increased risk of embolic events up to 180 days after community-acquired bacteremia. 9 We hypothesized that the risk of stroke in the setting of IE persists for longer than current data suggest. Therefore, we sought to better delineate the time period during which patients diagnosed with IE face an increased stroke risk.METHODS Study design. We performed a retrospective study of the temporal relationship between IE and stroke diagnoses using administrative claims data from California. The California Office of Statewide Health Planning and Development collects data about all emergency department (ED) visits and hospital stays at nonfederal acute care hospitals in California. After quality checking, these...

Clinical risk factors for acute ischaemic and haemorrhagic stroke in patients with infective endocarditis

“…Several studies have shown that the majority (60-74%) of strokes preceded diagnosis of IE. 11,[37][38][39] For the remaining IE patients without stroke at presentation, this study may offer guidance to clinicians who are treating patients at risk of developing strokes during hospital admission. In addition, 35.4% of the ischaemic strokes in our study underwent haemorrhagic conversion.…”

Cardioembolic Stroke

“…Approximately one in five cases of endocarditis are complicated by stroke, 44 and multiple studies have found a more than 20-fold relative increase in stroke risk in the month after a diagnosis of bacteremia 45 or infective endocarditis. 46 …”

Established and potential echocardiographic markers of embolism and their therapeutic implications in patients with ischemic stroke

“…In the study of Merkler et al [24] among 17,926 patients with IE, 2,275 strokes occurred within the 12-month period surrounding the diagnosis of IE.…”

“…Most diagnoses of stroke and IE are made close together in time, but a period of heightened stroke risk becomes apparent several months before the diagnosis of IE and lasts for several months afterward [24]. In the study of Merkler et al [24] among 17,926 patients with IE, 2,275 strokes occurred within the 12-month period surrounding the diagnosis of IE.…”

“…The risk of stroke was highest in the month after diagnosis of IE (1,640 vs. 17 strokes in the corresponding month 2 years prior) [24]. A transthoracic echocardiography must be performed in every case of suspected IE.…”