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Infective endocarditis in Portugal: Changing epidemiology but still a deadly disease
Endocardite infeciosa em Portugal: uma epidemiologia em evolução, mas ainda uma doença mortal
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The main reason for this apparent unchanged prognosis is because IE is a changing disease, with older patients with more severe disease, changing epidemiological profiles and greater numbers of patients with prosthetic valve or device-related infections.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Diagnostic strategies and management may differ between countries and these differences are currently investigated in the EURO-ENDO registry,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> which prospectively included 3116 adult patients (2470 from Europe, 646 from non-European Society of Cardiology (ESC) countries), admitted to 156 hospitals in 40 countries between January 2016 and March 2018 with a diagnosis of IE based on ESC 2015 diagnostic criteria.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this issue of the Portuguese Journal of Cardiology, de Sousa et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> present a systematic review of all published series of patients hospitalized with IE in Portuguese hospital centers.</p><p id="par0020" class="elsevierStylePara elsevierViewall">This review gives us the opportunity to compare the IE characteristics observed in Portugal to those of IE currently observed in other parts of the world, as reported in European Infective Endocarditis Registry (EURO-ENDO).<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Epidemiology of infective endocarditis</span><p id="par0025" class="elsevierStylePara elsevierViewall">In the series by de Sousa et al.,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> the mean age of patients was 55.5 ± 12.1 years, with a large predominance of males. This population is younger than that observed in EURO-ENDO and this may be related to the high number of intravenous drug users and to the inclusion of some relatively old studies with possibly younger patients. In three one-year population-based surveys conducted in 1991, 1999, and 2008,<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,6</span></a> the total IE incidence remained stable over time, but mean age progressively increased from 57.9 ± 16.6 years in 1991 to 61.6 ± 16.3 years in 2008. Similarly, the incidence of cardiac device-related IE (CDRIE) is increasing. Although observed in only 6.1% of cases in the Portuguese series, it is now much more frequent (9.9%) in EURO-ENDO,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> reflecting the increasing burden of IE in this older population. Conversely, the relatively high incidence of <span class="elsevierStyleItalic">enterococci</span> (11.7 to 15% of patients) reported by the current study corroborates the current increasing incidence of this microorganism (15.8%) reported in EURO-ENDO, again reflecting the increasing age of this population.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Imaging</span><p id="par0030" class="elsevierStylePara elsevierViewall">One of the most important changes in the diagnosis of IE is the implementation of non-echocardiographic imaging techniques, mainly cardiac computed tomography (CT) and <span class="elsevierStyleSup">18</span>F-fluorodeoxyglucose positron emission tomography / computed tomography (<span class="elsevierStyleSup">18</span>F-FDG PET/CT).<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8,10</span></a> These techniques are more and more frequently used in IE, particularly in the field of suspected prosthetic valve IE. For instance, [<span class="elsevierStyleSup">18</span>F]FDG PET/CT was performed in 16.6% of patients in EURO-ENDO (7), and multislice CT in 53.1% of patients. The low use of these techniques in Portuguese centers probably reflects the difficult access to nuclear imaging in some Portuguese cities. But more importantly, as reported by the authors, the main explanation is the inclusion of patients before the publication of the 2015 ESC guidelines,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> in which these new imaging tools were included for the first time in the diagnostic and prognostic stratification of IE. Nevertheless, the use of [18F]FDG PET/CT varied largely between countries across the world, ranging from 0.5 to 33.9% of IE cases in EURO-ENDO.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Treatment and prognosis in infective endocarditis</span><p id="par0040" class="elsevierStylePara elsevierViewall">At Portuguese centers, the reported surgical rate ranged from 3.1 to 52%, with a trend toward a higher surgical rate in the most recent series, with three main indications for surgery: heart failure (50 and 74%), uncontrolled infection (27.3 and 46.8%) and embolization (13.6 and 15.6%). These results support current ESC guidelines,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> in which early surgery is recommended as soon as one of these three complication occurs. In EURO-ENDO,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> we focused on the implementation of the ESC guidelines in clinical practice and found that, although theoretical indication for cardiac surgery was present in 69.3% patients, surgery was eventually performed during hospitalization in only 51.2% patients. Failure to perform surgery when indicated was associated with the worst prognosis in EURO-ENDO, emphasizing the benefit of an aggressive surgical strategy in these patients. The relatively high in-hospital and long-term mortality reported at Portuguese centers probably reflects the low use of surgery (29.8%) in some relatively old reported series.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusion and perspectives</span><p id="par0045" class="elsevierStylePara elsevierViewall">The report from de Sousa et al. (9), although limited by its retrospective nature and other issues reported by the authors, has the merit of emphasizing the main messages of EURO-ENDO, including the higher frequency of IE among the elderly, in prosthetic IE and in CDRIE, the value of new imaging techniques, still underused in several countries, the need for early surgical management, and the still poor prognosis of IE, particularly when surgery is indicated and cannot be performed. Endocarditis teams<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> are now in existence at several hospitals across Europe. They will help implementing the ESC guidelines in the future, both in terms of diagnostic and therapeutic strategies, and improving the prognosis of this devastating disease.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Epidemiology of infective endocarditis" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Imaging" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Treatment and prognosis in infective endocarditis" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion and perspectives" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infective endocarditis: a deadly disease if diagnosed too late" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 7 | 3 | 10 |
| 2024 Outubro | 35 | 46 | 81 |
| 2024 Setembro | 48 | 35 | 83 |
| 2024 Agosto | 43 | 32 | 75 |
| 2024 Julho | 34 | 34 | 68 |
| 2024 Junho | 36 | 30 | 66 |
| 2024 Maio | 31 | 17 | 48 |
| 2024 Abril | 28 | 31 | 59 |
| 2024 Maro | 32 | 22 | 54 |
| 2024 Fevereiro | 26 | 23 | 49 |
| 2024 Janeiro | 28 | 20 | 48 |
| 2023 Dezembro | 21 | 21 | 42 |
| 2023 Novembro | 33 | 35 | 68 |
| 2023 Outubro | 22 | 16 | 38 |
| 2023 Setembro | 25 | 23 | 48 |
| 2023 Agosto | 20 | 12 | 32 |
| 2023 Julho | 30 | 10 | 40 |
| 2023 Junho | 30 | 11 | 41 |
| 2023 Maio | 24 | 27 | 51 |
| 2023 Abril | 24 | 3 | 27 |
| 2023 Maro | 21 | 21 | 42 |
| 2023 Fevereiro | 28 | 18 | 46 |
| 2023 Janeiro | 26 | 18 | 44 |
| 2022 Dezembro | 34 | 20 | 54 |
| 2022 Novembro | 44 | 31 | 75 |
| 2022 Outubro | 44 | 24 | 68 |
| 2022 Setembro | 29 | 38 | 67 |
| 2022 Agosto | 27 | 34 | 61 |
| 2022 Julho | 29 | 48 | 77 |
| 2022 Junho | 26 | 33 | 59 |
| 2022 Maio | 24 | 32 | 56 |
| 2022 Abril | 39 | 43 | 82 |
| 2022 Maro | 32 | 42 | 74 |
| 2022 Fevereiro | 24 | 35 | 59 |
| 2022 Janeiro | 33 | 31 | 64 |
| 2021 Dezembro | 25 | 37 | 62 |
| 2021 Novembro | 37 | 37 | 74 |
| 2021 Outubro | 35 | 53 | 88 |
| 2021 Setembro | 19 | 31 | 50 |
| 2021 Agosto | 35 | 54 | 89 |
| 2021 Julho | 20 | 21 | 41 |
| 2021 Junho | 32 | 34 | 66 |
| 2021 Maio | 33 | 49 | 82 |
| 2021 Abril | 129 | 100 | 229 |
| 2021 Maro | 144 | 92 | 236 |
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