Infective Endocarditis Incidence Among High-Risk Patients

Study Questions:

What is the incidence of infective endocarditis (IE) among high-risk patients (those having prior IE, a prosthetic heart valve, or cyanotic heart disease) compared to controls?

Methods:

Using Danish nationwide registries (1996–2015), all patients with prior IE, a prosthetic heart valve, or complex cyanotic heart disease (defined as tetralogy of Fallot, truncus arteriosus, and transposition of the great arteries) were identified. For each study group, patients were matched by age (a difference of ≤2 years was accepted) and gender with controls from the general population, with four controls for every case. Patients were followed up until death, end of study period, IE hospitalization, emigration, or a maximum of 10 years of follow-up, whichever came first. Multivariable adjusted Cox proportional hazard analysis was used to compare the risk of IE between the study groups and the matched controls.

Results:

A total of 25,945 patients were included: 5,096 had prior IE, 19,478 had a prosthetic heart valve, and 1,371 had complex cyanotic heart disease. The cumulative risk of IE at 10 years of follow-up was 8.8%, 6.0%, and 1.3% for patients with prior IE, a prosthetic valve, and complex cyanotic heart disease, respectively. Patients with prior IE and a prosthetic valve had a significantly increased associated risk of IE compared with the matched controls (hazard ratio [HR], 65.4; 95% confidence interval [CI], 43.1–99.1; and HR, 19.1; 95% CI, 15.0–24.4, respectively). No events occurred among the matched controls for the complex cyanotic heart disease group, and an HR could not be calculated.

Conclusions:

All IE high-risk groups carried a higher risk of IE than the matched controls from the general population. The authors concluded that these results justify the European and American guidelines in considering these groups at high risk of IE.

Perspective:

These data from 1996–2015 Danish nationwide registries confirm that patients with prior IE, a prosthetic heart valve, or complex cyanotic heart disease are at higher risk than age- and gender-matched controls for the development of IE. Although the European guidelines (Baumgartner H, et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J 2017;38:2739-91) do not specify, the American guidelines (Nishimura RA, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease. J Am Coll Cardiol 2014;63:e57-e185) recommend the use of IE prophylaxis among patients at high risk of an adverse outcome related to IE, not necessarily at high risk of getting IE. This study did not compare the high-risk groups of prior IE, a prosthetic heart valve, or complex cyanotic congenital heart disease with patients with native valve disease—another group also at increased lifetime risk of developing IE, but not included in recommendations for IE prophylaxis.

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Cardiac Surgery and CHD & Pediatrics, Cardiac Surgery and VHD, Congenital Heart Disease, CHD & Pediatrics and Interventions, CHD & Pediatrics and Quality Improvement, Interventions and Structural Heart Disease

Keywords: Cardiac Surgical Procedures, Endocarditis, Endocarditis, Bacterial, Heart Defects, Congenital, Heart Valve Diseases, Heart Valve Prosthesis, Risk Factors, Tetralogy of Fallot, Transposition of Great Vessels, Truncus Arteriosus


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