Valvular and Congenital Disease
The risk of stroke and death in patients with aortic and mitral valve endocarditis,☆☆

https://doi.org/10.1067/mhj.2001.115790Get rights and content

Abstract

Background Previous studies have generated inconsistent results when attempting to define predictors of stroke and death in patients with endocarditis. We sought to examine the relationship between vegetation 2-dimensional size and stroke in those with infective endocarditis (IE) and to identify differences between aortic valve (AV) and mitral valve (MV) IE with regard to clinical characteristics, echocardiographic findings, stroke, and death. Methods We used the Duke Endocarditis Database to examine 145 episodes of definite IE involving the AV, n = 62, or MV, n = 83. A logistic regression model was developed to analyze important variables in predicting stroke, and a Cox proportional hazards model was used in predicting mortality. Results The mitral valve was infected in 57% of the cases. Vegetations were more commonly detected in patients with MV IE (92.8% vs 66.1%, P =.001) and these MV vegetations were significantly larger (P <.05). Thirty-four of 145 episodes (23.4%) were complicated by stroke. MV IE was associated with a greater stroke rate, 32.5% versus 11.3% (P =.003). Strokes tended to occur early in the course of illness, particularly in MV IE. In the multivariable model, the independent predictors of stroke were MV IE (P =.04) and vegetation length (P =.03). Independent predictors of 1-year mortality were age (P =.02) and vegetation area (P =.048). Conclusion Stroke is more common in patients with MV IE. Vegetation 2-dimensional size and characteristics are important predictors of stroke and mortality. These findings may lead to predictive models that allow physicians to identify high-risk patients who need aggressive treatment strategies to prevent long-term morbidity and mortality. (Am Heart J 2001;142:75-80.)

Section snippets

Patient selection

A total of 2114 consecutive patients who underwent a transthoracic (TTE) or a transesophageal echocardiogram (TEE) for suspicion of endocarditis during the period from Jan 1, 1991, through Dec 31, 1999, were evaluated. Patients were enrolled if they were suspected to have IE and were not rejected by the Duke criteria.24 Demographic, clinical, microbiologic, pathologic, and echocardiographic data were collected from each patient’s medical record and clinical course. Of the 450 patients with

Demographic features

There were 145 patients with definite IE and isolated MV or AV involvement. The mean age of the cohort was 54.5 years (Table I).

. Characteristics of 145 patients with aortic or mitral valve endocarditis

Empty CellTotal (n = 145)
No.%
Age (y) (mean ± SD)54.5 ± 15.3
MV endocarditis8357.2
AV endocarditis6242.8
Male sex8860.7
Race
 White8056.3
 Black5538.7
Intravenous drug use139.0
HIV positive42.8
Presence of prosthetic valve6242.8
Dialysis2215.2
Diabetes mellitus3322.8
History of cancer106.9
Immune suppression139.0
Transfer

Discussion

There are important differences in the demographic characteristics and echocardiographic findings between cases of MV IE and cases of AV IE. These differences include the risk of stroke. Stroke is 1.5 times more common in all patients with MV IE and more than 5 times more common in cases of native MV IE. In addition, preventable strokes tend to occur much earlier in patients with MV IE. In a multivariable analysis, valve location and vegetation length were the only independent predictors of

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    Supported by the following grants: American Society of Echocardiography: Outcomes Research Award (C. H. C., G. E. P., G. R. C., T. R.), Four Schools Physician Scientist Program sponsored by the Lucille P. Markee Charitable Trust (C. H. C.), and Joseph C. Greenfield Jr Scholars (C. H. C.).

    ☆☆

    Reprint requests: Christopher H. Cabell, MD, DUMC Box 31020, Durham, NC 27710. E-mail: [email protected]

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