Infective endocarditis: a tenth of patients died and half required cardiac surgery.

Clinical bottom line (level 2b)

  1. Vegetations were common in patients with infective endocarditis.
  2. Around a tenth of patients had sterile blood cultures.
  3. Around half required cardiac surgery mainly for left heart failure.
  4. A tenth of patients with infective endocarditis died in hospital. The risk was increased in patients with:
    • infected prosthetic valve
    • systemic embolisation
    • Staphylococcus aureus
Jaffe et al: 1990; 15: 1221-1226
Expires July 2003

The study

Retrospective cohort study with objective outcomes, adjusted for confounding factors, not validated in an independent set of patients.

Setting: university hospital, USA, 1983 to 1988

70 patients (aged range 15 to 88 years; mean 47, 57% male) infective endocarditis who had echocardiography. Patients were considered to have it if at least one of the following criteria were met:
  • at surgery or autopsy, valvular vegetations or embolic material, or both, were present with histologic or bacteriologic evidence of active infection (n=40)
  • two or more positive sets of blood cultures in the presence of a new regurgitant murmur or systemic embolism (n=26)
  • when two of the following conditions were present: fever >38.5 degrees C, new regurgitant murmur, embolic phenomenon (n=4- all of whom had one set of positive blood cultures)


Excluded if
  • no echocardiography or technically unsatisfactory



    • Factors studied:
  • mortality
  • infected prosthetic valve
  • systemic embolisation
  • staphylococcus aureus
  • vegetation >10 mm in size (systemic embolism)




    • Multivariate regression analysis performed on risk factors

    100% followed for until discharge
    Outcomes studied:
  • mortality
  • vegetation on echocardiography mass of abnormal echoes met all of the following criteria- attached to an endocardial surface, seen consistently through the cardiac cycle, apparent in multiple views, and displayed motion independent of cardiac structure, and was distinct in echogenicity from the valve or endocardial surface
  • indication for cardiac surgery: left ventricular failure
  • indication for cardiac surgery: recurrent embolism
  • indication for cardiac surgery: uncontrolled infection
  • indication for cardiac surgery: combination of these factors

    • The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    mortality until discharge 7/70 10%
    (3.0% to 17%)
    vegetation on echocardiography until discharge 54/69 78%
    (69% to 88%)
    indication for cardiac surgery: left ventricular failure until discharge 18/70 26%
    (15% to 36%)
    indication for cardiac surgery: recurrent embolism until discharge 6/70 9%
    (2% to 15%)
    indication for cardiac surgery: uncontrolled infection until discharge 4/70 6%
    (0% to 11%)
    indication for cardiac surgery: combination of these factors until discharge 8/70 11%
    (4% to 19%)

    prognostic factor for
    vegetation on echocardiography     		time to outcome adjusted RR
    (95% CI)    		 NNF+
    (95% CI)
    vegetation >10 mm in size (systemic embolism) until discharge 2.32
    (0.55 to 9.77)     		7
    (-1 to 20)

    • Blood cultures were positive in 63 patients (90%) (95% CI: 83% to 97%).

    Citation

    1. Jaffe WM, et al: Infective endocarditis, 1983-1988: echocardiographic findings and factors influencing morbidity and mortality. 1990; 15: 1221-1226
    Search Terms: endocarditis and echocardiography
    Contributor: Carl Heneghan, Sumit Dhingra and Chris Ball, July 2000
    Reviewer:

    Clinical Question.
    Patient suspected endocarditis
    Intervention or Exposure echo
    Outcome mortality, vegetations