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. 2021 Apr;116(4):682-691.
doi: 10.36660/abc.20190586.

Neurological Complications in Patients with Infective Endocarditis: Insights from a Tertiary Centre

[Article in English, Portuguese]
Sofia Alegria  1 , Ana Marques  1 , Inês Cruz  1 , Ana Luísa Broa  1 , Ana Rita F Pereira  1 , Isabel João  1 , Otília Simões  1 , Hélder Pereira  1
Affiliations

Neurological Complications in Patients with Infective Endocarditis: Insights from a Tertiary Centre

[Article in English, Portuguese]
Sofia Alegria et al. Arq Bras Cardiol. 2021 Apr.

Abstract
in English, Portuguese

Background: Neurological complications are common in patients with infective endocarditis (IE). Recent data suggest that neurologic events are a major determinant of prognosis, and that surgery is critical in improving the outcome.

Objective: To characterize patients with IE and neurological complications and to determine predictors of embolization to the central nervous system (CNS) and mortality.

Methods: Retrospective analysis of patients admitted to a tertiary center with the diagnosis of IE from 2006 to 2016. Statistical significance was defined by a p-value < 0.05.

Results: We identified 148 episodes of IE, 20% of which had evidence of CNS embolization. In patients with CNS embolization, 76% presented with ischemic stroke. During follow-up, 35% were submitted to surgery and both in-hospital and one-year mortality were 39%. These patients had longer hospitalizations, but there were no significant differences regarding mortality in patients with and without CNS embolization. The independent predictors of neurological complications were diabetes (p=0.005) and the absence of fever at presentation (p=0.049). Surgery was associated with lower mortality (0 vs. 58%; p=0.003), while patients with septic shock had a poorer prognosis (75 vs. 25%; p=0.014). In multivariate Cox regression, human immunodeficiency virus (HIV) infection was the only independent predictor of in-hospital and 1-year mortality (p=0.011 in both).

Conclusions: In this population, embolization to the CNS was common, more often presented as ischemic stroke, and was associated with longer hospitalization, although without significant differences in mortality. In patients with CNS embolization, those submitted to surgery had a good clinical evolution, while patients with septic shock and HIV infection had a worse outcome. These results should be interpreted with caution, taking into consideration that patients with more severe complications or more fragile were probably less often considered for surgery, resulting in selection bias.

Fundamento: Complicações neurológicas são comuns em pacientes com endocardite infecciosa (EI). Dados recentes sugerem que os eventos neurológicos são os principais determinantes do prognóstico e que a cirurgia é crítica para melhorar o resultado.

Objetivo: Caracterizar pacientes com EI e complicações neurológicas e determinar preditores de embolização para o sistema nervoso central (SNC) e mortalidade.

Métodos: Análise retrospectiva de pacientes internados em centro terciário com diagnóstico de EI no período de 2006 a 2016. Significância estatística foi definida por um valor de p <0,05.

Resultados: Identificamos 148 episódios de EI, 20% dos quais tinham evidências de embolização do SNC. Em pacientes com embolização do SNC, 76% apresentaram acidente vascular cerebral isquêmico. Durante o seguimento, 35% foram submetidos à cirurgia e a mortalidade hospitalar e em um ano foi de 39%. Esses pacientes tiveram hospitalizações mais longas, mas não houve diferenças significativas em relação à mortalidade em pacientes com e sem embolização do SNC. Os preditores independentes de complicações neurológicas foram diabetes (p = 0,005) e ausência de febre na apresentação (p = 0,049). A cirurgia foi associada a menor mortalidade (0 vs. 58%; p = 0,003), enquanto os pacientes com choque séptico tiveram pior prognóstico (75 vs. 25%; p = 0,014). Na regressão multivariada de Cox, a infecção pelo vírus da imunodeficiência humana (HIV) foi o único preditor independente de mortalidade hospitalar e de 1 ano (p = 0,011 em ambos).

Conclusões: Nessa população, a embolização para o SNC foi comum, mais frequentemente apresentada como acidente vascular cerebral isquêmico, e esteve associada a maior tempo de internação, embora sem diferenças significativas na mortalidade. Nos pacientes com embolização do SNC, os submetidos à cirurgia tiveram boa evolução clínica, enquanto os pacientes com choque séptico e infecção pelo HIV tiveram pior evolução. Esses resultados devem ser interpretados com cautela, levando em consideração que os pacientes com complicações mais graves ou mais frágeis foram provavelmente menos considerados para a cirurgia, resultando em viés de seleção.

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Conflict of interest statement

Potencial conflito de interesses

Os autores declaram não haver conflito de interesses pertinentes.

Figures

Figura 1
Figura 1. Complicações neurológicas em pacientes com endocardite (n = 29).
Figura 2
Figura 2. Curva de sobrevida de Kaplan-Meier de pacientes com endocardite e complicações neurológicas de acordo com o estado de infecção pelo vírus da imunodeficiência HIV: vírus da imunodeficiência humana.
Figure 1
Figure 1. Neurological complications in patients with endocarditis (n=29).
Figure 2
Figure 2. Kaplan-Meier survival curve of patients with endocarditis and neurological complications according to the status of human immunodeficiency virus infection. HIV: Human immunodeficiency virus.
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