Infective endocarditis: Do we have an effective risk score model? A systematic review

Abstract

BackgroundInfective endocarditis (IE) is a rare, highly morbid condition with 17% in-hospital mortality. A total of 25–30% require surgery and there is ongoing debate with regard to markers predicting patient outcomes and guiding intervention. This systematic review aims to evaluate all IE risk scores currently available.MethodsStandard methodology (PRISMA guideline) was used. Papers with risk score analysis for IE patients were included, with attention to studies reporting area under the receiver-operating characteristic curve (AUC/ROC). Qualitative analysis was carried out, including assessment of validation processes and comparison of these results to original derivation cohorts where available. Risk-of-bias analysis illustrated according to PROBAST guidelines.ResultsOf 75 articles initially identified, 32 papers were analyzed for a total of 20 proposed scores (range 66–13,000 patients), 14 of which were specific for IE. The number of variables per score ranged from 3 to 14 with only 50% including microbiological variables and 15% including biomarkers. The following scores had good performance (AUC > 0.8) in studies proposing the score (often the derivation cohort); however fared poorly when applied to a new cohort: PALSUSE, DeFeo, ANCLA, RISK-E, EndoSCORE, MELD-XI, COSTA, and SHARPEN. DeFeo score demonstrated the largest discrepancy with initial AUC of 0.88, compared to 0.58 when applied to different cohorts. The inflammatory response in IE has been well documented and CRP has been found to be an independent predictor for worse outcomes. There is ongoing investigation on alternate inflammatory biomarkers which may assist in IE management. Of the scores identified in this review, only three have included a biomarker as a predictor.ConclusionDespite the variety of available scores, their development has been limited by small sample size, retrospective collection of data and short-term outcomes, with lack of external validation, limiting their transportability. Future population studies and large comprehensive registries are required to address this unmet clinical need.

Multidisciplinary Perspectives of Challenges in Infective Endocarditis Complicated by Septic Embolic-Induced Acute Myocardial Infarction

“…Antimicrobial therapy is also essential for treating the underlying infection. The decision regarding the timing of surgical intervention in this case should be made by the endocarditis team [ 2 , 14 , 58 ].…”

“…The occurrence of conduction abnormalities, such as arrhythmias or heart blocks, in IE complicated by septic embolic-induced AMI may have a dual mechanism: it may be the consequence of the obstruction of the vessel irrigating the atrioventricular node or the extension of the infection beyond the valve annulus. The atrioventricular block may occur not only as a complication of the paravalvular extension of the infection but can also develop as a consequence of AMI [ 2 , 58 ].…”

“…For treatment, coronary angiography, splenectomy, surgical embolectomy, percutaneous abscess drainage, or endovascular interventions may be required in some cases, with a concurrent supportive and antimicrobial treatment [ 2 , 13 , 14 , 58 ].…”

“…Despite improvements in the management of IE, the mortality rate at discharge remains high, ranging between 20 and 30% [ 1 ]. Mortality and morbidity of IE are mainly due to the progression to uncontrolled infection (UI) and embolic events (EE) and are also due to heart failure (HF) [ 2 ]. The septic embolic event is a common complication in IE [ 3 ] and is associated with a poor prognosis.…”