Infective endocarditis: affected mainly the left heart and many patients had valvular heart disease.

Clinical bottom line (level 4)

  1. The left side of the heart was most commonly affected in patients with infective endocarditis.
  2. Many had valvular heart disease or prosthetic heart valves.
  3. Fever occurred in most cases- two thirds had an extra-cardiac manifestation.
Delahaye et al: European Heart Journal 1995; 16: 394-401
Expires July 2003

The study

Case-control study with ?objective ?blinded outcomes, not adjusted for confounding factors, not validated in an independent set of patients.

Setting: any hospital, three regions of France, 1990 to 1991

415 patients (aged range 7 days to 91 years; mean 56 years, 64% male) definite, probable or possible infective endocarditis (by modified von Reyn criteria)

Excluded if
  • questionnaire not returned (n=14)
  • hospitalisation outside the study period (n=52)
  • case rejected according to diagnostic criteria (n=22)
  • patient resident outside the study region (n=72)





    • Outcomes studied:
  • no previously known heart disease
  • native valve disease
  • prosthetic valve
  • miscellaneous ventricular septal defect, atrial septal defect, tetralogy of Fallot, bicuspid aortic valve, other congenital abnormalities, pacemaker, obstructive cardiomyopathy, ischaemic cardiomyopathy, cardiac murmur
  • endocarditis in left heart
  • endocarditis in right heart
  • endocarditis in both left and right heart
  • endocarditis in congenital abnormality
  • fever
  • at least one extra-cardiac phenomena splenomegaly, emboli, petechiae, subungual or conjunctival haemorrhage, Roth spots, Osler nodes, Janeway lesions, meningitis, haematuria, glomerulonephritis
  • CNS emboli
  • splenomegaly
  • pulmonary emboli
  • other emboli
  • other extra-cardiac phenomena

    • von Reyn criteria:
      • definite: direct evidence of infective endocarditis based on histology from surgery or autopsy or on bacteriology (Gram's stain or culture) of valvular vegetation or peripheral embolus
      • probable: (a) persistently positive blood cultures, plus one of the following: new regurgitant murmur; predisposing heart disease and vascular phenomena (petechiae, splinter haemorrhages, conjunctival haemorrhages, Roth spots, Osler's nodes, Janeway lesions, aseptic meningitis, glomerulonephritis and pulmonary, CNS, coronary or peripheral emboli). (b) negative or intermittently positive blood cultures plus three of the following: fever; new regurgitant murmur; vascular phenomena
      • possible: (a) persistently positive blood cultures plus one of the following: predisposing heart disease; vascular phenomena. (b) negative or intermittently positive blood cultures with all three of the following: fever; predisposing hear disease; valvular phenomena. (c) for viridans streptococcal cases only- at least two positive blood cultures without an extra-cardiac source and fever
      • rejected: (a) endocarditis unlikely- alternative diagnosis is already apparent. (b) endocarditis likely, empiric antibiotic therapy warranted. (c) culture negative endocarditis diagnosed clinically, but excluded by post-mortem

    The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    no previously known heart disease ? 141/415 34%
    (29% to 39%)
    native valve disease ? 139/415 33%
    (29% to 38%)
    prosthetic valve ? 90/415 22%
    (18% to 26%)
    miscellaneous ? 45/415 11%
    (8% to 14%)
    endocarditis in left heart ? 355/404 88%
    (85% to 91%)
    endocarditis in right heart ? 29/404 7%
    (5% to 10%)
    endocarditis in both left and right heart ? 10/404 2%
    (1% to 4%)
    endocarditis in congenital abnormality ? 10/404 2%
    (1% to 4%)
    fever ? 390/415 94%
    (92% to 96%)
    at least one extra-cardiac phenomena ? 257/415 62%
    (57% to 67%)
    CNS emboli ? 100/415 24%
    (20% to 28%)
    splenomegaly ? 62/415 15%
    (12% to 18%)
    pulmonary emboli ? 29/415 7%
    (5% to 9%)
    other emboli ? 42/415 10%
    (7% to 13%)
    other extra-cardiac phenomena ? 125/415 32%
    (26% to 35%)

    • During the first two months after admission, 24% of the patients underwent surgery, and 17% of all patients died.
    • Diagnostic agreement between the patient's physician and the investigators was 76%.

    Citation

    1. Delahaye , et al: Characteristics of infective endocarditis in France in 1991. European Heart Journal 1995; 16: 394-401
    Search Terms: endocarditis, epidemiology
    Contributor: Carl Heneghan, Sumit Dhingra and Chris Ball, July 2000
    Reviewer:

    Clinical Question.
    Patient suspected endocarditis
    Intervention or Exposure clinical findings, prevalence
    Outcome diagnosis of infective endocarditis