Neurologic Complications of Infective Endocarditis: Risk Factors, Outcome, and Impact of Cardiac Surgery: A Multicenter Observational Study

May 10, 2013
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Authors:
García-Cabrera E, Fernández-Hidalgo N, Almirante B, et al.
Citation:
Circulation 2013;May 6:[Epub ahead of print].
Summary By:
David S. Bach, MD, FACC

Study Questions:

Among patients with left-sided infective endocarditis (IE), what is the incidence of neurologic complications, the risk factors for their development, their influence on clinical outcome, and the impact of cardiac surgery?

Methods:

Prospectively collected data from a multicenter cohort of 1,345 consecutive episodes of left-sided IE from eight centers in Spain were retrospectively analyzed. Cox regression models were developed to analyze variables predictive of neurologic complications and associated mortality.

Results:

A total of 340 patients (25%) experienced neurologic complications: 192 patients (14%) had an ischemic event, 86 (6%) encephalopathy/meningitis, 60 (5%) hemorrhage, and two brain abscess. Independent risk factors associated with all neurologic complications were: vegetation size ≥3 cm (hazard ratio [HR], 1.91), Staphylococcus aureus etiology (HR, 2.47), mitral valve involvement (HR, 1.29), and anticoagulant therapy (HR, 1.31). Anticoagulant therapy was particularly related to a greater incidence of hemorrhagic events (HR, 2.71). Overall mortality was 30%, and neurologic complications had a negative impact on outcomes (45% of deaths vs. 24% in patients without neurologic complications, p < 0.01), although only moderate to severe ischemic stroke (HR, 1.63) and brain hemorrhage (HR, 1.73) were significantly associated with a poorer prognosis. Antimicrobial treatment reduced (by 33% to 75%) the risk of neurologic complications. In patients with hemorrhage, mortality was higher when surgery was performed within 4 weeks of the hemorrhagic event (75% vs. 40% with later surgery).

Conclusions:

Moderate to severe ischemic stroke and brain hemorrhage were found to have a significant negative impact on the outcome of IE. The authors concluded that early, appropriate antimicrobial treatment is critical, and transitory discontinuation of anticoagulant therapy should be considered.

Perspective:

Left-sided IE is a serious condition associated with substantial mortality and morbidity even with appropriate treatment. Data from this large patient cohort reinforce the substantial risk of neurologic complications associated with IE.

Keywords: Prognosis, Spain, Risk Factors, Meningitis, Staphylococcus aureus, Brain Abscess, Endocarditis, Bacterial


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