Q fever endocarditis in Spain. Clinical characteristics and outcome.

OBJECTIVES: To describe the clinical presentation of a large number of Q fever endocarditis (QFE) and its management considering the role of serology. PATIENTS AND METHODS: Eighty-three patients with definite QFE (56 native and 27 prosthetic valve) with a long-term follow-up after stopping treatment (median: 48 months) were included. Final outcome (cure or relapse) was compared according with the serological titre at the end of therapy: less than 1:400 of phase I Ig G antibodies by indirect immunofluorescence (group 1, N=23) or more than 1:400 (group 2, N=30). RESULTS: Eleven patients (13.2%) died from QFE and other 8 died for other reasons not related to endocarditis during follow-up. Surgery was performed in 61 (73.5%) patients and combined antimicrobial treatment was long (median: 23 months, IQR: 12 - 36). Seven relapses were observed, but five of them had received an initial incomplete antibiotic regimen. In patients who completed the programmed treatment (range: 12 - 89 months), serological titres at the end of therapy were not useful for predicting the final outcome: one relapse in each group. CONCLUSIONS: QFE requires a prolonged antimicrobial treatment, but serological titres are not useful for determining its duration.

Clinical features and outcome of non-drug-addicted patients with infective endocarditis and perivalvular abscess.

BACKGROUND AND AIM OF THE STUDY: Perivalvular abscess is a serious complication in infective endocarditis (IE) that confers a poor prognosis. Few data are available concerning the long-term outcome of these patients. The study aim was to determine clinical features and long-term prognosis of non-drug addict patients with IE complicated by perivalvular abscess. METHODS: Among a consecutive series of 241 patients with IE, 30 (12.4%) were diagnosed with perivalvular abscess and treated at the authors' institution over a 15-year period. A comparative analysis of patients with perivalvular abscess and other patients in the series was performed. RESULTS: Perivalvular abscess was more frequently associated with aortic valve endocarditis (93% versus 35%, p <0.05), and Streptococcus sp. was the predominant microorganism. Severe complications during hospital admission were more common in patients with perivalvular abscess (100% versus 61%, p <0.01). In-hospital mortality was significantly higher in patients with perivalvular abscess (33% versus 15%, p <0.05). Event-free survival at five years among survivors of the in-hospital phase was 86% in patients with perivalvular abscess, and 83% in those without abscess (p = NS). CONCLUSION: Patients with IE and perivalvular abscess have a higher in-hospital mortality rate, as major complications are more common in these patients. However, among patients who survived the active phase of the disease, long-term survival was similar with or without perivalvular abscess.

Long-term prognosis of early and late prosthetic valve endocarditis.

A prospective series of 78 cases of prosthetic valve endocarditis (PVE) was studied (35 cases of early PVE and 43 cases of late PVE). The in-hospital mortality rate was significantly higher in patients with early PVE (31% vs 9%, p <0.01) because the onset of heart failure was more common in these patients (55% vs 37%, p <0.05). However, event-free survival at 4 years in survivors to the active phase was not different (74% and 82%, respectively).

[Risk factors associated with endocarditis without underlying heart disease]. / Factores de riesgo asociados a endocarditis sin cardiopatía predisponente.

Infective endocarditis (IE) pathogenesis has changed in the last decades and there is an increasing number of patients without predisposing heart condition. The aim of this study is to asses the clinical features of these non-drug addict patients affected with IE without underlying heart disease and to identify the potential risk factors. From 196 cases of IE, 49 (25% of the series) occurred in patients without underlying heart disease. A presumed portal of entry was identified in the majority (26 cases). The most frequent were digestive (6 cases), haemodialysis (6 cases) and central venous catheters (4 cases). Right heart valves were more often affected (29 vs 6%; p < 0.01). The distribution of the causative microorganism showed a higher proportion of Staphylococcus (57 vs 30%). Despite a similar in-hospital complication rate and a similar need of surgery during the active phase, their prognosis is better than in those with underlying heart disease.

In-hospital mortality due to acute myocardial infarction. relevance of type of hospital and care provided. RECALCAR study.

INTRODUCTION AND OBJECTIVES: To investigate the relationship between in-hospital mortality due to acute myocardial infarction and type of hospital, discharge service, and treatment provided. METHODS: Retrospective analysis of 100 993 hospital discharges with a principal diagnosis of myocardial infarction in hospitals of the Spanish National Health Service. In-hospital mortality was adjusted for risk following the models of the Institute for Clinical Evaluative Sciences (Canada) and the Centers for Medicare & Medicaid Services (United States). RESULTS: Hospital characteristics are relevant to explain the variation in the individual probability of dying from myocardial infarction (median odds ratio: 1.3561). The risk-adjusted in-hospital mortality in cluster 3 and especially in cluster 4 hospitals (500 beds to 1000 beds and medium-high complexity) was significantly lower than in hospitals with less than 200 beds. Cluster 5 (more than 1000 beds), which includes a diverse group of hospitals, had a higher mortality rate than clusters 3 and 4. The adjusted mortality in the groups with the best and worst outcomes was 6.74% (cluster 4) and 8.49% (cluster 1), respectively. Mortality was also lower when the cardiology unit was responsible for the discharge or when angioplasty had been performed. CONCLUSIONS: The typology of the hospital, treatment in a cardiology unit, and percutaneous coronary intervention are significantly associated with the survival of a patient hospitalized for myocardial infarction. We recommend that the Spanish National Health Service establish health care networks that favor percutaneous coronary intervention and the participation of cardiology units in the management of patients with acute myocardial infarction.

Infective endocarditis after the Ross procedure.

The Ross procedure is presumed to have a lower incidence of infective endocarditis during follow-up compared to other traditional aortic replacement procedure. We describe 4 cases of infective endocarditis during follow-up of 96 patients who underwent the Ross procedure in our institution. All episodes occurred in patients with a previously dysfunctioning graft. One patient required surgery during the active phase of the infective endocarditis. Clinical outcome was successful in all patients and no one died during follow-up. In conclusion, the incidence of infective endocarditis in patients operated on using the Ross procedure is not negligible. The potential beneficial effect of the Ross procedure with respect to a higher resistance to infection should be evaluated in large prospective series.

[Changing epidemiology of native valve infective endocarditis]. / Cambios epidemiológicos de la endocarditis infecciosa sobre válvula nativa.

INTRODUCTION AND OBJECTIVES: The aim of our study is to assess changes in the epidemiologic features of patients with native valve infective endocarditis. METHODS: We analyzed a prospective series of 228 cases of native valve infective endocarditis in non-intravenous drug users attending our center between 1987 and 2009. We compared three subperiods: 1987-1994 (67 cases), 1995-2002 (74 cases) and 2003-2009 (87 cases). RESULTS: The mean age of patients has progressively increased (38±22 years in the first subperiod vs 60±16 years in the third; P<.001), as has the proportion of cases without predisposing heart disease (25%, 46% and 67%; P<.001). Incidence of mitral valve prolapse remained stable (12%, 18% and 11%). Percentages of patients with predisposing heart disease and who were aware of their condition have fallen in recent years (45%, 27% and 21%; P<.001). A portal of entry for the infection could not be identified in 64%. Overall, Staphylococcus aureus is the most frequent causative organism (26%) whereas the percentage of cases caused by Streptococcus viridans remains unaltered (22%, 20% and 24%). CONCLUSIONS: We found significant changes in the epidemiology of native valve infective endocarditis. The incidence of patients without predisposing heart disease has increased significantly and staphylococci are the most frequent causative organisms. Full English text available from: www.revespcardiol.org.

Effect of statin treatment on mortality in a large cohort of heart failure patients.

We studied 3162 heart failure patients included in the Spanish BADAPIC registry in order to determine whether statin treatment influences prognosis. Patients were followed up for 35 +/- 22 months (median, 32 months). Patients on statins were more often male and had higher prevalences of risk factors, ischemic heart disease and systolic dysfunction (P< .001) than those not on statins. After adjustment for age, risk factors, ischemic heart disease, renal failure, ejection fraction, anemia, heart rate and drug treatment, statin treatment was found to be a favorable independent predictor of survival: the hazard ratio for mortality was 0.73 (95% confidence interval, 0.45-0.88; P< .001). During follow-up, the 3-year survival rate was higher in patients treated with statins (75% vs. 68%; P< .001). In patients with heart failure, statin treatment appears to be independently associated with better survival.

Outcome of heart failure with preserved ejection fraction: a multicentre spanish registry.

BACKGROUND: Studies on clinical features, treatment and prognosis of patients with congestive heart failure (CHF) and preserved left ventricular ejection fraction (LVEF) are few and their results frequently conflicting. AIMS: To investigate the characteristics and long term prognosis of patients with CHF and preserved (≥ 45%) LVEF. METHODS AND RESULTS: We conducted a prospective multicentre study with 4720 patients attended in 62 heart failure clinics from 1999 to 2003 in Spain (BADAPIC registry). LVEF was preserved in 30% patients. Age, female gender, prevalence of atrial fibrillation, hypertension and non-ischaemic cardiopathy were all significantly greater in patients with preserved LVEF. Mean follow-up was 40±12 months. Mortality and other cardiovascular complication rates during follow up were similar in both groups. On multivariate analysis ejection fraction was not an independent predictor for mortality. Survival at one and five years was similar in both groups (79% and 59% for patients with preserved LVEF and 78% and 57% for those with reduced LVEF, respectively). CONCLUSIONS: In the BADAPIC registry, a high percentage of heart failure patients had preserved LVEF. Although clinical differences were seen between groups, morbidity and mortality were similar in both groups.

[Clinical characteristics and prognosis of infective endocarditis in women]. / Características clínicas y pronóstico de la endocarditis infecciosa en la mujer.

INTRODUCTION AND OBJECTIVES: Little is known about the prognosis of infective endocarditis in women. The objective of this study was to determine the clinical characteristics and prognosis of infective endocarditis in women diagnosed with the condition at our center during the last 20 years. METHODS: Comparative analysis of 288 patients diagnosed with infective endocarditis between 1987 and 2006. Of these, 104 (36%) were women. RESULTS: Mean age was similar in the two sexes, at 50 (18) years for men and 52 (21) years for women, as was the incidence of early and late prosthetic valve endocarditis: the incidence of early prosthetic endocarditis was 42% in men and 49% in women. Infection occurred more frequently in the mitral valve in women (54% vs. 39%) and more frequently in the aortic valve in men (50% vs. 29%; P< .01). The severe complication rate during the active disease phase was similar in the two sexes (76% for women and 73% for men). Fewer women underwent surgery during the active disease phase (44% versus 58%; P< .03), and there was a trend to higher mortality in women (24% versus 20.7%; (24% versus 20.7%; P<.1). The 5-year survival rate was similar in the two sexes, at 85% in men and 83% in women. CONCLUSIONS: The clinical characteristics of infective endocarditis were similar in men and women. However, women underwent surgery less frequently despite a similar rate of severe complications during the active disease phase.

Mortalidad intrahospitalaria por infarto agudo de miocardio. Relevancia del tipo de hospital y la atención dispensada. Estudio RECALCAR / In-hospital mortality due to acute myocardial infarction. Relevance of type of hospital and care provided. RECALCAR study

Introducción y objetivos. Investigar la relación entre mortalidad intrahospitalaria por infarto agudo de miocardio y tipología del hospital, servicio de alta y tratamiento dispensado. Métodos. Análisis retrospectivo de 100.993 altas por infarto en los hospitales del Sistema Nacional de Salud. La mortalidad se ajustó por riesgo utilizando los modelos del Institute of Clinical Evaluative Sciences (Canadá) y de los Centers for Medicare & Medicaid Services (Estados Unidos). Resultados. Las características de los hospitales son relevantes para explicar la variación de la probabilidad individual de morir por infarto (odds ratio mediana = 1,3561). La mortalidad intrahospitalaria ajustada por riesgo fue significativamente menor en los hospitales de los clusters 3 y 4 (500 a 1.000 camas y complejidad mediana-alta) que en hospitales de menos de 200 camas. El cluster 5 (más de 1.000 camas), que es muy heterogéneo, tenía mayor mortalidad que los clusters 3 y 4. Las diferencias de la mortalidad ajustada entre el grupo con mejores y peores resultados fueron del 6,74% (cluster 4) y el 8,49% (cluster 1) (p < 0,001). La mortalidad también fue menor cuando el servicio de cardiología se encargó del alta, así como cuando se practicó angioplastia. Conclusiones. Las características del hospital, ser atendido por un servicio de cardiología y el intervencionismo coronario se asocian con la supervivencia intrahospitalaria del paciente con infarto. Se recomienda la creación de redes asistenciales en el Sistema Nacional de Salud que favorezcan el intervencionismo coronario y la participación de los servicios de cardiología en el manejo de pacientes con infarto agudo de miocardio (AU)

Introduction and objectives. To investigate the relationship between in-hospital mortality due to acute myocardial infarction and type of hospital, discharge service, and treatment provided. Methods. Retrospective analysis of 100 993 hospital discharges with a principal diagnosis of myocardial infarction in hospitals of the Spanish National Health Service. In-hospital mortality was adjusted for risk following the models of the Institute for Clinical Evaluative Sciences (Canada) and the Centers for Medicare & Medicaid Services (United States). Results. Hospital characteristics are relevant to explain the variation in the individual probability of dying from myocardial infarction (median odds ratio: 1.3561). The risk-adjusted in-hospital mortality in cluster 3 and especially in cluster 4 hospitals (500 beds to 1000 beds and medium-high complexity) was significantly lower than in hospitals with less than 200 beds. Cluster 5 (more than 1000 beds), which includes a diverse group of hospitals, had a higher mortality rate than clusters 3 and 4. The adjusted mortality in the groups with the best and worst outcomes was 6.74% (cluster 4) and 8.49% (cluster 1), respectively. Mortality was also lower when the cardiology unit was responsible for the discharge or when angioplasty had been performed. Conclusions. The typology of the hospital, treatment in a cardiology unit, and percutaneous coronary intervention are significantly associated with the survival of a patient hospitalized for myocardial infarction. We recommend that the Spanish National Health Service establish health care networks that favor percutaneous coronary intervention and the participation of cardiology units in the management of patients with acute myocardial infarction (AU)

Cambios epidemiológicos de la endocarditis infecciosa sobre válvula nativa / Changing epidemiology of native valve infective endocarditis

Introducción y objetivos. El objetivo de nuestro estudio es evaluar los cambios producidos en los aspectos epidemiológicos de la endocarditis sobre válvula nativa. Métodos. Estudiamos una serie prospectiva de 228 casos con endocarditis sobre válvula nativa en pacientes no usuarios de drogas por vía parenteral atendidos en nuestra institución desde 1987 hasta 2009, y comparamos tres periodos de estudio: 1987-1994 (67 casos), 1995-2002 (74 casos) y 2003-2009 (87 casos). Resultados. La media de edad de los pacientes ha aumentado progresivamente (38±22 años en el primer periodo frente a 60±16 años en el tercero; p<0,001), así como la proporción de casos sin cardiopatía predisponente (el 25, el 46 y el 67%; p<0,001). La incidencia de prolapso valvular mitral ha permanecido estable (el 12, el 18 y el 11%). La tasa de pacientes portadores de una cardiopatía predisponente y conocedores de ella se redujo significativamente en los últimos años (el 45, el 27 y el 21%; p<0,001). No se pudo identificar una puerta de entrada a la infección en el 64% de los casos. En general, Staphylococcus aureus es el germen causal más frecuente (26%), mientras que la proporción de casos por Streptococcus viridans no se ha modificado (el 22, el 20 y el 24%). Conclusiones. Se han producido cambios significativos en la epidemiología de la endocarditis infecciosa sobre válvula nativa. La incidencia de casos de endocarditis sin cardiopatía predisponente está aumentando significativamente y en ella los estafilococos siguen siendo los más frecuentes (AU)

Introduction and objectives. The aim of our study is to assess changes in the epidemiologic features of patients with native valve infective endocarditis. Methods. We analyzed a prospective series of 228 cases of native valve infective endocarditis in non-intravenous drug users attending our center between 1987 and 2009. We compared three subperiods: 1987-1994 (67 cases), 1995-2002 (74 cases) and 2003-2009 (87 cases). Results. The mean age of patients has progressively increased (38±22 years in the first subperiod vs 60±16 years in the third; P<.001), as has the proportion of cases without predisposing heart disease (25%, 46% and 67%; P<.001). Incidence of mitral valve prolapse remained stable (12%, 18% and 11%). Percentages of patients with predisposing heart disease and who were aware of their condition have fallen in recent years (45%, 27% and 21%; P<.001). A portal of entry for the infection could not be identified in 64%. Overall, Staphylococcus aureus is the most frequent causative organism (26%) whereas the percentage of cases caused by Streptococcus viridans remains unaltered (22%, 20% and 24%). Conclusions. We found significant changes in the epidemiology of native valve infective endocarditis. The incidence of patients without predisposing heart disease has increased significantly and staphylococci are the most frequent causative organisms (AU)

Q fever endocarditis in Spain. Clinical characteristics and outcome

Objectives To describe the clinical presentation of a large number of Q fever endocarditis (QFE) and its management considering the role of serology. Patients and methods Eighty-three patients with definite QFE (56 native and 27 prosthetic valve) with a long-term follow-up after stopping treatment (median: 48 months) were included. Final outcome (cure or relapse) was compared according with the serological titre at the end of therapy: less than 1:400 of phase I Ig G antibodies by indirect immunofluorescence (group 1, N=23) or more than 1:400 (group 2, N=30).Results Eleven patients (13.2%) died from QFE and other 8 died for other reasons not related to endocarditis during follow-up. Surgery was performed in 61 (73.5%) patients and combined antimicrobial treatment was long (median: 23 months, IQR: 12 – 36). Seven relapses were observed, but five of them had received an initial incomplete antibiotic regimen. In patients who completed the programmed treatment (range: 12 – 89 months), serological titres at the end of therapy were not useful for predicting the final outcome: one relapse in each group. Conclusions QFE requires a prolonged antimicrobial treatment, but serological titres are not useful for determining its duration (AU)

Objetivos Describir la presentación clínica de la endocarditis por fiebre Q (EFQ) y su manejo terapéutico, así como el papel de la serología en este aspecto. Pacientes y método Se incluyeron 83 casos de EFQ definidas (56 nativas y 27 protésicas) con un seguimiento prolongado después de la finalización del tratamiento (mediana de 48 meses). La evolución final (curación o recidiva) se comparó dividiendo los casos en dos grupos según el título serológico al final del tratamiento: menos de 1:400 para Ac Ig G en fase I mediante inmunofluorescencia indirecta (grupo 1, N=23) o más de 1:400 (grupo 2, N=30).Resultados Once pacientes (13.2%) murieron por EFQ y otros 8 lo hicieron durante el seguimiento por diversas razones no relacionadas con la endocarditis. Fueron operados 61 (73.5%) pacientes y el tratamiento antimicrobiano fue muy prolongado (mediana: 23 meses, RIQ: 12 – 36). Siete pacientes recidivaron al cesar el tratamiento, pero cinco de ellos no habían completado el inicialmente programado. En los pacientes que sí completaron el tratamiento antimicrobiano (rango: 12 – 89 meses), los títulos serológicos observados al final del mismo no fueron útiles para predecir la evolución final, observándose una recidiva en cada uno de los grupos. Conclusiones La EFQ requiere un tratamiento antimicrobiano prolongado, pero los títulos serológicos no son un instrumento útil para determinar su duración (AU)

Características clínicas y pronóstico de la endocarditis infecciosa en la mujer / Clinical characteristics and prognosis of infective endocarditis in women

Introducción y objetivos. El pronóstico de la endocarditis infecciosa en la mujer ha sido poco estudiado. El objetivo del presente estudio es analizar las características clínicas y el pronóstico de las mujeres con endocarditis infecciosa atendidas en nuestra institución en los últimos 20 años. Métodos. Análisis comparativo de 288 pacientes con endocarditis infecciosa desde 1987 hasta 2006. De ellos, 104 (36%) eran mujeres. Resultados. La media de edad fue similar en ambos grupos (50 ± 18 años los varones y 52 ± 21 las mujeres), así como la incidencia de endocarditis sobre prótesis precoz y tardía (endocarditis protésica precoz: varones, 42%; mujeres, 49%). La infección se localizó con mayor frecuencia en la válvula mitral en las mujeres (el 54 frente al 39%) y en la válvula aórtica en los varones (el 50 frente al 29%; p < 0,01). La tasa de complicaciones severas durante la fase activa fue similar en ambos grupos (el 73% en varones y el 76% en mujeres). Se intervino a mujeres con menor frecuencia durante la fase activa de la enfermedad (el 44 frente al 58%; p < 0,03) y hubo una tendencia a una mayor mortalidad precoz en las mujeres que en los varones (el 24 frente al 20,7%; p < 0,1). La supervivencia a los 5 años fue similar en ambos grupos (el 85% en los varones y el 83% en las mujeres). Conclusiones. Las características clínicas de la endocarditis infecciosa son similares en varones y mujeres; sin embargo, las mujeres se operan con menor frecuencia a pesar de una tasa similar de complicaciones severas durante la fase activa (AU)

Introduction and objectives. Little is known about the prognosis of infective endocarditis in women. The objective of this study was to determine the clinical characteristics and prognosis of infective endocarditis in women diagnosed with the condition at our center during the last 20 years. Methods. Comparative analysis of 288 patients diagnosed with infective endocarditis between 1987 and 2006. Of these, 104 (36%) were women. Results. Mean age was similar in the two sexes, at 50 (18) years for men and 52 (21) years for women, as was the incidence of early and late prosthetic valve endocarditis: the incidence of early prosthetic endocarditis was 42% in men and 49% in women. Infection occurred more frequently in the mitral valve in women (54% vs. 39%) and more frequently in the aortic valve in men (50% vs. 29%; P<.01). The severe complication rate during the active disease phase was similar in the two sexes (76% for women and 73% for men). Fewer women underwent surgery during the active disease phase (44% versus 58%; P<.03), and there was a trend to higher mortality in women (24% versus 20.7%; P<.1). The 5-year survival rate was similar in the two sexes, at 85% in men and 83% in women. Conclusions. The clinical characteristics of infective endocarditis were similar in men and women. However, women underwent surgery less frequently despite a similar rate of severe complications during the active disease phase (AU)