Preditores de desfechos adversos em longo prazo na endocardite infecciosa

Abstract

Introduction: despite advances in the management of patients with infective endocarditis (IE), this disease continues to have severe complications with high in-hospital mortality. Even after hospital discharge patients are at risk for adverse events. The most common complications described at long-term after an initial episode of IE are repeat IE, embolic and neurological events, heart failure (HF), need for cardiac surgery and death. When considering long-term management of IE survivors, there is a lack of evidence on prognosis, specially of prospective studies. Therefore, the aim of this study is to identify predictors of major adverse events on long-term follow up in a large prospective cohort of patients who have been treated for prior IE, in the current era of evidence-based recommendations for treatment. Methods: this was a cohort that included 263 consecutive patients with IE admitted to the Hospital das Clínicas da Universidade Federal de Minas Gerais from 2004 to 2019. Long-term follow-up data were collected preferably during visits at the institution`s outpatient clinic, through phone contacts or through their medical records. The primary outcome was a composite of overall mortality and cardiac surgery. Cox regression models were used to determine the characteristics that were independently associated with the primary outcome. Results: the median age was 52 years, 60.5% were male and 30.2% had rheumatic heart disease (RHD). During the index hospitalization 90 patients died (34.2%) and 57.5% were operated. All 173 who survived were included in the long-term follow-up. The median follow-up time was 3.5 years (interquartile range 1.29-7.47). The primary outcome was reached in 29.5% of the cases, overall mortality was 20.4% and cardiovascular mortality was 7%. Cardiac surgery was performed in 11.2% of patients. Age (HR 1.026; 95% IC 1.006-1.047; p=0.012), chronic kidney disease (CKD) (HR 4.265; 95% CI 2.035-8.938; p<0.001), neurological complications at hospital admission (HR 2.237; 95% CI 1.006-4.976; p=0.048) and aggravated or refractory HF during treatment (HR 1.982; 95% CI 1.035-3.795; p=0.039) were identified as independent predictors of the primary outcome. Conclusion: in a cohort of 263 patients with prior IE, characterized by younger individuals, with a high prevalence of rheumatic heart disease (RHD) and cardiac implantable electronic devices (CIED), adverse outcomes were found in 30% of the patients at long-term follow-up. The independent predictors of outcomes were increasing age, previous CKD, neurological complications and aggravated or refractory HF during treatment, after adjustment for other prognostic factors. Therefore, considering this high rate of adverse events, all patients who had IE should be closely monitored after discharge, irrespective of the presence of these risk factors for worse outcome.