A Nationwide Cohort Study of Mortality Risk and Long-Term Prognosis in Infective Endocarditis in Sweden

Anders Ternhag,Anna Törner,Katarina Westling,Agneta Cederström,Michael Alan Polis

doi:10.1371/journal.pone.0067519

Abstract

Objectives: Infective endocarditis (IE) remains a serious disease with substantial mortality. In this study we investigated the incidence of IE, as well as its associated short and long term mortality rates.MethodsThe IE cases were identified in the Swedish national inpatient register using ICD-10 codes, and then linked to the population register in order to identify deaths in the cohort. Crude mortality rates among IE patients were obtained for different time intervals. These rates were directly standardized using sex- and age-matched mortality in the general population.ResultsThe cohort consisted of 7603 individuals and 7817 episodes of IE during 1997–2007. The 30 days all-cause crude mortality rate was 10.4% and the standardized mortality ratio (SMR) was 33.7 (95% confidence interval [CI]: 31.0–36.6). Excluding the first year of follow-up, the long term mortality (1–5 years) showed an increased SMR of 2.2 (95% CI: 2.0–2.3) compared to the general population. Significantly higher SMR was found for cases of IE younger than 65 years of age with a 1–5 year SMR of 6.3, and intravenous drug-users with a SMR of 19.1. Native valve IE cases, in which surgery was performed had lower crude mortality rates and Mantel-Haenzel odds ratios of less than one compared to those with medical therapy alone during 30-day and 5-years follow-up.ConclusionsThe 30-days crude mortality rate for IE was 10.4% and long-term relative mortality risk remains increased even up to 5 years of follow-up, therefore a close monitoring of these patients would be of value.

Highlights

Infective endocarditis (IE) is a serious disease which is caused by a bacterial or fungal infection of endocardial surfaces of the heart, most often the valves
The diagnostic criteria for endocarditis have changed [5] and transesophageal echocardiography has become more common, there are reasons to believe that the same incidence rate is true for other years and parts of Sweden
There are indications that the long-term mortality risk following an episode of IE is heightened

Summary

Introduction

Infective endocarditis (IE) is a serious disease which is caused by a bacterial or fungal infection of endocardial surfaces of the heart, most often the valves. The diagnostic criteria for endocarditis have changed [5] and transesophageal echocardiography has become more common, there are reasons to believe that the same incidence rate is true for other years and parts of Sweden. The short term mortality i.e. within 30 days from the diagnosis of disease is reported to be 10 to 30% in studies from different countries and depends on age, co-morbidity, etiology and whether it is a native or prosthetic valve IE [6]. There are indications that the long-term mortality risk following an episode of IE is heightened. This could be due to recurrence of infection or complications of IE such as heart failure. It could be a result of the changing patient groups of IE with underlying diseases and/or intravascular devices (as opposed to young adults with rheumatic valve disease or congenital heart abnormalities) [7], and an increase in incidence of Staphylococcus aureus IE [8]

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