Neurologic Complications of Infective Endocarditis: Risk Factors, Outcome, and Impact of Cardiac Surgery: A Multicenter Observational Study
Background—This study assesses the incidence of neurologic complications in IE patients, the risk factors for their development, their influence on the clinical outcome, and the impact of cardiac surgery.
Methods and Results—Retrospective analysis of prospectively collected data on a multicenter cohort of 1345 consecutive episodes of left-sided IE from 8 centers in Spain. Cox regression models were developed to analyze variables predictive of neurologic complications and associated mortality. Three hundred and forty patients (25%) experienced such complications: 192 patients (14%) had ischemic events, 86 (6%) encephalopathy/meningitis, 60 (5%) hemorrhages, and 2 brain abscesses. Independent risk factors associated with all neurologic complications were: vegetation size ≥3 cm (HR 1.91), Staphylococcus aureus etiology (HR 2.47), mitral valve involvement (HR 1.29), and anticoagulant therapy (HR 1.31). This last variable was particularly related to a greater incidence of hemorrhagic events (HR 2.71). Overall mortality was 30%, and neurologic complications had a negative impact on the outcome (45% of deaths vs. 24% in patients without these complications; p<0.01), although only moderate-severe ischemic stroke (HR 1.63) and brain hemorrhage (HR 1.73) were significantly associated with a poorer prognosis. Antimicrobial treatment reduced (by 33%-75%) the risk of neurologic complications. In patients with hemorrhage, mortality was higher when surgery was performed within 4 weeks of the hemorrhagic event (75% vs 40% in later surgery).
Conclusions—Moderate-severe ischemic stroke and brain hemorrhage were found to have a significant negative impact on the outcome of IE. Early, appropriate antimicrobial treatment is critical, and transitory discontinuation of anticoagulant therapy should be considered.
- Received December 28, 2012.
- Revision received April 15, 2013.
- Accepted April 26, 2013.