Background:
Stroke is a common, serious complication of infective endocarditis (IE). It is not known how recent advances in management have changed the profile and outcome of IE-related stroke.
Methods:
We retrospectively reviewed data of all inpatients with ICD-9 diagnostic codes of IE admitted to our tertiary hospital from 1980-2011. Original Duke Criteria were used to confirm the diagnosis. Data was compared over 3 time epochs: 1980-1990 (E1), 1991-2000 (E2) and 2001-2011 (E3).
Results:
Of 1151 hospitalizations (1083 adults), 277 included IE-related stroke (76% ischemic, 13% hemorrhagic, 10% both). There was an increasing rate of stroke over the 3 epochs (E1 25%, E2 30%, E3 45%; p<0.001), perhaps due to increased detection from increasing MRI use (E1 6%, E2 27%, E3 67%; p<0.001). Stroke patients had mean age 56 yrs, 63% male, 93% definite IE per Duke Criteria and 83% native valve infection. Organism types were staph 40%, strep 30% and other 30%. Trans-esophageal echo was performed in 53%. Over time there was no change in age, gender, and organism type; however there was an increasing frequency of native valve infection (E1 74%, E2 82%, E3 88%; p=0.04), ‘definite’ IE (E1 80%, E2 94%, E3 100%; p<0.001), cardiovascular risk factors (hypertension, diabetes, etc), and more patients underwent TEE (E1 9%, E2 67%, E3 68%; p<0.001). Brain imaging showed higher detection of multiple (vs. single) lesions (E1 67%, E2 66%, E3 88%; p<0.001), and ischemic (vs. hemorrhagic) strokes (E1 74%, E2 84%, E3 95%; p<0.001), presumably due to increasing MRI use, although the frequency of anticoagulant use also decreased (E1 45%, E2 35%, E3 26%; p=0.04). There was a trend towards improved outcome (p=0.12) with fewer deaths in 2001-2011 vs. 1980-2000 (22% vs. 33%; p=0.06). Logistic regression showed that age, anticoagulant use, stroke type, MRI performance, but not organism type or time epoch, predicted death at discharge.
Conclusion:
This large retrospective study spanning 3 decades shows important changes in the profile of IE-related stroke. While patient demographics and organism type appear unchanged, there is a higher rate of stroke detection and lower rates of complications such as brain hemorrhage and death rates, suggesting efficacy of recent diagnostic and management advances.
The clinical profile of native-valve infective endocarditis in a tertiary hospital in the Philippines: a twelve-year retrospective study
