Sex Differences in Native-Valve Infective Endocarditis in a Single Tertiary-Care Hospital

doi:10.1016/j.amjcard.2010.02.019

The American Journal of Cardiology

Volume 106, Issue 1, 1 July 2010, Pages 92-98

https://doi.org/10.1016/j.amjcard.2010.02.019 Get rights and content

The aim of this study was to assess whether the clinical characteristics, management, and outcomes of infective endocarditis differ in women and men through a prospective observational cohort study at a single tertiary care teaching hospital. From January 2000 to December 2008, 271 new cases of infective endocarditis were diagnosed (183 in men, 88 in women) according to modified Duke criteria, and patients were followed for 1 year. Women were older than men (mean age 63 ± 16 vs 58 ± 18 years, p = 0.006); more women were taking immunosuppressants (14% vs 3%, p = 0.006) and had mitral valve involvement (52% vs 36%, p = 0.02). However, more men had human immunodeficiency virus infection than women. There were no gender differences in Charlson index, regurgitation severity, culprit pathogens, or major complications. When surgery was indicated, women were less likely to undergo the procedure (26% vs 47%, relative risk [RR] 0.4, 95% confidence interval [CI] 0.2 to 0.7), p = 0.001). Mortality tended to be higher in women in the hospital (32% vs 23%, RR 1.58, 95% CI 1 to 2.5, p = 0.05) and at 1 year (38% vs 26%, RR 1.7, 95% CI 1.0 to 2.9, p = 0.04). Surgical treatment was a protective factor against death in the hospital (RR 0.18, 95% CI 0.04 to 0.77, p = 0.02) and at 1 year (RR 0.12, 95% CI 0.03 to 0.48, p = 0.03) after adjustment for age, gender, Charlson index, infection by Staphylococcus aureus, severity at presentation, heart failure, acute renal failure, stroke, and the ejection fraction. In conclusion, women with infective endocarditis were slightly older than men but showed similar co-morbidities. Women underwent surgery less frequently and consequently had worse prognosis than men.

Section snippets

Methods

This was a prospective observational cohort study at a single tertiary care hospital. The center is a 1,250-bed teaching hospital that includes all major medical and surgical departments and is a referral center for cardiac surgery. All consecutive patients aged ≥18 years diagnosed with confirmed or possible IE according to the modified Duke classification⁸ who were treated from January 2000 to December 2008 were enrolled. Patients were identified by the cardiology or infectious diseases

Results

A total of 271 episodes of IE in 264 patients were studied; 183 (67.5%) occurred in men and 88 (32.5%) in women. The mean age of patients was 57 ± 18 years. Differences in baseline clinical characteristics, echocardiographic findings, and clinical course are listed in Table 1.

Women were older than men, and more women than men were taking immunosuppressants, although more men had human immunodeficiency virus infections than women. Charlson index on admission, rate of nosocomial IE, culprit

Discussion

This is the first study to systematically evaluate gender difference in native valve IE. Our study revealed gender differences in patient and clinical characteristics, management, and prognosis of IE. Our data collection process was consistent because the study was conducted at a single tertiary care teaching hospital, and the medical and surgical team remained stable throughout the study period, ensuring homogeneity concerning clinical decisions.

Women with IE were older than men in our study

Acknowledgment

We thank Nancy Boblett and Mary Ellen Kerans for their assistance with the English in some versions of this report.

References (18)

D. Koya et al.
Infective endocarditis
N Engl J Med
(2002)
D.R. Murdoch et al.
Clinical presentation, etiology and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis—Prospective Cohort Study 2009
Arch Intern Med
(2009)
C.H. Cabell et al.
Progress toward a global understanding of infective endocarditisEarly lessons from the International Collaboration on Endocarditis investigation
Infect Dis Clin N Am
(2002)
R. Moreno et al.
Influence of diabetes mellitus on the short and long term outcome in patients with active infective endocarditis
J Heart V Dis
(2002)
O. Aksoy et al.
Gender differences in infective endocarditis: pre- and co-morbid conditions lead to different management and outcomes in female patients
Scand J Infect Dis
(2007)
V. Vaccarino et al.
Sex and racial differences in the management of acute myocardial infarction, 1994 through 2002
N Engl J Med
(2005)
N. Akhter et al.
Gender differences among patients with acute coronary syndromes undergoing percutaneous coronary intervention in the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR)
Am Heart J
(2009)
J.S. Li et al.
Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis
Clin Infect Dis
(2000)
M.E. Charlson et al.
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation
J Chronic Dis
(1987)

There are more references available in the full text version of this article.

Cited by (58)

Trends in the incidence and mortality of infective endocarditis in high-income countries between 1990 and 2019
2023, International Journal of Cardiology
Citation Excerpt :
This is an important finding that warrants further attention. While pathophysiolological explanations remain speculative, a number of studies have categorised different features of IE in males and females, and demonstrate that females with IE are older with more co-morbidities, more likely to have severe manifestations of IE and less likely to undergo early surgical intervention [39,40]. This was an observational study and, whilst possible explanations are provided, causality cannot be attributed.
Infective endocarditis (IE) remains a life-threatening disease with high morbidity and mortality.
To describe temporal trends in IE incidence, mortality and survival over the last 30 years.
Nineteen high-income countries (the ‘EU 15+’) were included. Age-standardised and sex-stratified incidence rates (ASIRs) and mortality rates (ASMRs) for IE were extracted from the Global Burden of Disease (GBD) database between 1990 and 2019, and mortality to incidence ratios (ASMIRs) were calculated. Trends were analysed using Joinpoint regression analysis.
ASIRs were higher in males than females and increased in both sexes in all countries between 1990 and 2019. A recent steep rise in ASIRs was noted in several countries including the UK, the USA and Germany. ASMRs increased for both sexes in all countries except Finland and Austria. The largest increase in ASMR was observed in females in Italy (+246%). ASMIRs were generally higher in females compared to males, with large increases in ASMIRs (indicating worsening survival) at the end of the 20th century, but more recent stabilisation or decline across the study cohort.
While the incidence and mortality of IE have increased over the last 30 years, recent data suggest that these trends have plateaued or reversed in most countries studied. However, a recent surge in incidence in several countries (including the USA and UK) is of concern, while unfavourable outcomes in females also merit attention. More encouragingly, this analysis provides the first indication of improving IE survival at population level, supporting recent advances in diagnosis and treatment.
Sex Differences in Infective Endocarditis After Transcatheter Aortic Valve Replacement
2022, Canadian Journal of Cardiology
Citation Excerpt :
The high relative proportion of culture-negative episodes found in women (10%) highlights the importance of serologic analysis, antinuclear antibodies investigation, or valvular biopsies when available in this subpopulation.15 It has been previously suggested that the impaired prognosis of women after IE in non-TAVR patients was related to the reduced likelihood of undergoing surgery when indicated.8 Moreover, it is known that women are less likely to receive cardiovascular therapies.16-18
Outcomes after transcatheter aortic valve replacement (TAVR) and infectious diseases may vary according to sex.
This multicentre study aimed to determine the sex differences in clinical characteristics, management, and outcomes of infective endocarditis (IE) after TAVR. A total of 579 patients (217 women, 37.5%) who had the diagnosis of definite IE following TAVR were included retrospectively from the Infectious Endocarditis After TAVR International Registry.
Women were older (80 ± 8 vs 78 ± 8 years; P = 0.001) and exhibited a lower comorbidity burden. Clinical characteristics and microbiological profiles were similar between men and women, but culture-negative IE was more frequent in women (9.9% vs 4.3%; P = 0.009). A high proportion of patients had a clinical indication for surgery (54.4% in both groups; P = 0.99), but a surgical intervention was performed in a minority of patients (women 15.2%, men 20.3%; P = 0.13). The mortality rate at index IE hospitalisation was similar in both groups (women 35.4%, men 31.7%; P = 0.37), but women exhibited a higher mortality rate at 2-year follow-up (63% vs 52.1%; P = 0.021). Female sex remained an independent risk factor for cumulative mortality in the multivariable analysis (adjusted HR 1.28, 95% CI 1.02-1.62; P = 0.035). After adjustment for in-hospital events, surgery was not associated with better outcomes in women.
There were no significant sex-related differences in the clinical characteristics and management of IE after TAVR. However, female sex was associated with increased 2-year mortality risk.
Le pronostic des patients après implantation de valve aortique par voie percutanée (TAVI) et après la survenue de pathologies infectieuses peut varier en fonction du sexe.
Cette étude multicentrique visait à déterminer les différences entre les sexes concernant les caractéristiques cliniques, la prise en charge et le pronostic de l'endocardite infectieuse (EI) après TAVI. Au total, 579 patients (217 femmes, 37,5 %) ayant un diagnostic d'endocardite infectieuse après TAVI ont été inclus rétrospectivement dans le : Infectious Endocarditis After TAVR International Registry.
Les femmes étaient plus âgées (80 ± 8 vs 78 ± 8 ans; P = 0,001) et présentaient un taux de comorbidité plus faible. Les caractéristiques cliniques et les profils microbiologiques étaient similaires entre les hommes et les femmes, mais les EI à l'hémoculture négative étaient plus fréquentes chez les femmes (9,9 % vs 4,3 %; P = 0,009). Une proportion élevée de patients avaient une indication clinique d'intervention chirurgicale (54,4 % dans les deux groupes; P = 0,99), mais une intervention chirurgicale a été pratiquée pour une minorité de patients (femmes : 15,2 %, hommes : 20.3 %; P = 0,13). Le taux de mortalité lors de l'hospitalisation pour EI était similaire dans les deux groupes (femmes 35,4 %, hommes 31,7 %; P = 0,37), mais les femmes présentaient un taux de mortalité plus élevé lors du suivi à deux ans (63 % contre 52,1 %; P = 0,021). Le sexe féminin est resté un facteur de risque indépendant de mortalité dans l'analyse multivariée (Rapport des risques instantanés ajusté 1,28, IC à 95 % 1,02-1,62; P = 0,035). Après ajustement en fonction des événements indésirables survenus à l'hôpital, la chirurgie n'était pas associée à un meilleur pronostic chez les femmes.
Il n'y avait pas de différences significatives liées au sexe dans les caractéristiques cliniques et la prise en charge de l'EI après TAVI. Cependant, le sexe féminin était associé à un risque accru de mortalité à deux ans.
2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
2021, Journal of Thoracic and Cardiovascular Surgery
Sex differences in health resource utilization, costs and mortality during hospitalization for infective endocarditis in the United States
2021, American Heart Journal Plus: Cardiology Research and Practice
Few studies have assessed the association between sex and outcomes among patients with infective endocarditis. The aim of the study was to better understand the association between biologic sex, clinical outcomes and surgical treatment patterns among a contemporary cohort of patients admitted to hospital with infective endocarditis.
We used the National Inpatient Sample dataset from the Health Care Utilization Project to identify adult patients admitted for infective endocarditis between January and December 2016. We compared outcomes between men and women including inpatient hospital mortality, direct hospital costs, length of stay, and inpatient surgical treatment patterns. Multivariable analyses were performed with adjustment for age, socioeconomic status, and comorbidity burden.
Among 18,702 patients with infective endocarditis, there were 8730 (46.7%) women and 1753 (8.4%) in-hospital deaths. In multivariable analysis, female sex was associated with a trend toward lower in-hospital mortality (adjusted odds ratio (OR) 0.90; 95% confidence interval (CI) 0.80 to 1.01, p = 0.06). Additionally, female sex was associated with significantly shorter hospital length of stay (−0.5 days; 95% CI −0.88 to −0.12, p = 0.009) and lower hospital costs (−$3035; 95% CI −$4277 to −$1792; p < 0.001). Notably, women were less likely to undergo surgical intervention (adjusted OR 0.59; 95% CI 0.52 to 0.67, p < 0.001).
In a contemporary, nationally representative cohort of patients admitted for IE in the United States, there were sex-specific differences in management and in-hospital outcomes. Possible sex-based bias in treatment patterns and access to inpatient surgical intervention for infective endocarditis warrants further study.
2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
2021, Journal of the American College of Cardiology
2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
2021, Journal of the American College of Cardiology
This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.
A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline.
Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

View all citing articles on Scopus

: This study was supported by grant RD 06/0014/0025 from the Spanish Network for Research in Cardiovascular Diseases. Drs. Fernández-Hidalgo, Almirante, and Pahissa were supported by grant RD 06/0008 from the Spanish Network for Research in Infectious Diseases.

View full text

Valvular heart diseaseSex Differences in Native-Valve Infective Endocarditis in a Single Tertiary-Care Hospital

Section snippets

Methods

Results

Discussion

Acknowledgment

Infective endocarditis

N Engl J Med

Clinical presentation, etiology and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis—Prospective Cohort Study 2009

Arch Intern Med

Progress toward a global understanding of infective endocarditisEarly lessons from the International Collaboration on Endocarditis investigation

Infect Dis Clin N Am

Influence of diabetes mellitus on the short and long term outcome in patients with active infective endocarditis

J Heart V Dis

Gender differences in infective endocarditis: pre- and co-morbid conditions lead to different management and outcomes in female patients

Scand J Infect Dis

Sex and racial differences in the management of acute myocardial infarction, 1994 through 2002

N Engl J Med

Gender differences among patients with acute coronary syndromes undergoing percutaneous coronary intervention in the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR)

Am Heart J

Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis

Clin Infect Dis

A new method of classifying prognostic comorbidity in longitudinal studies: development and validation

J Chronic Dis

Valvular heart disease
Sex Differences in Native-Valve Infective Endocarditis in a Single Tertiary-Care Hospital