Prediction of Symptomatic Embolism in Filipinos With Infective Endocarditis Using the Embolic Risk French Calculator

Abstract

BackgroundCardioembolic events are life-threatening complications of infective endocarditis (IE). The embolic risk French calculator estimates the embolic risk in IE computed on admission. Variables in this tool include age, diabetes, atrial fibrillation, prior embolism, vegetation length, and Staphylococcus aureus on culture. A computed risk of > 7% was considered high in the development of this tool. Knowledge of this risk applied in our local setting is important to guide clinicians in preventing such catastrophic complications. Among patients with IE, we aim to determine the efficacy of the embolic risk French calculator, using a computed score of > 7%, in predicting major embolic events.MethodsAll adults admitted from 2013 to 2016 with definite IE were included. The risk for embolic events was computed on admission. All were monitored for the duration of admission for the occurrence of the primary outcome (any major embolic event: arterial emboli, intracranial hemorrhage, pulmonary infarcts, or aneurysms). Secondary outcomes were: 1) composite of death and embolic events; and 2) death from any cause.ResultsEighty-seven adults with definite IE were included. Majority had a valvular heart disease and preserved ejection fraction (EF). The mitral valve was most commonly involved. Embolic events occurred in 25 (29%). Multivariate analysis identified a high embolic score > 7% (relative risk (RR): 15.12, P < 0.001), vegetation area ≥ 18 mm2 (RR: 6.39, P < 0.01), and a prior embolism (RR: 5.18, P = 0.018) to be independent predictors of embolic events. For the composite of embolic events and death, independent predictors include a high score of > 7% (RR: 13.56, P < 0.001) and a prior embolus (RR: 13.75, P = 0.002). Independent predictors of death were a high score > 7% (RR: 6.20, P = 0.003) and EF ≤ 45% (RR: 9.91, P = 0.004).ConclusionCardioembolic events are more prevalent in our study compared to previous data. The embolic risk French calculator is a useful tool to estimate and predict risk for embolic events and in-hospital mortality. The risk of developing embolic events should be weighed against the risks of early preventive cardiac surgery, as to institute timely and appropriate management.

Clinical and echocardiographic predictors of embolism in infective endocarditis: systematic review and meta-analysis

“…Citations excluded after full-text screening are listed in the Supplementary material. All studies were of cohort design; 37 were retrospective [3,5,6,13,22e25,27e30,32,34e39,41,42,45e60] and ten were prospective [8,11,12,21,26,31,33,40,43,44]. Studies were primarily in English (n ¼ 41) [3,5,6,8,11e13,21e44,48e51,54e57,59,60], with additional studies in French [58], Spanish [46], German [47,53], Czech [52] and Chinese [45].…”

“…All studies (except for one) counted systemic emboli as EEs; twelve studies also included pulmonary emboli [3,5,6,21,30,32,36,44,46,48,53,57], two studies included cutaneous emboli [6,29] and four studies included silent emboli [31,43,49,60]. Twelve studies included only new EEs occurring after admission or antibiotic therapy initiation [3,11,12,21,24,32,37,39,41,42,44,56], and two studies excluded EEs occurring after cardiac surgery [3,26]. One study did not define EEs [41].…”

“…Among 11 studies including patients with EEs occurring at various times and reporting data, the overall proportion of patients with EEs whose embolism occurred before initiation of antibiotics was 53.3% (95% CI 38.0%e68.1%; see Supplementary material, Fig. S2) [3,6,8,11,13,26,28,30,43,44,56]. Of 34 studies pooled in meta-analyses of echocardiographic characteristics, six used transthoracic echocardiography [24,27,30,36,58,59], six used trans-oesophageal echocardiography [6,8,21,26,34,52], 16 used both [3,5,11,22,23,31e33, 37,44,46,48,49,53,56,57], and six did not specify the modality [13,28,45,47,51,55].…”

Prediction of Acute-phase Complications in Patients with Infectious Endocarditis

“…Since the French Calculator was designed by Hubert et al (11) to predict new embolic events in IE, several investigators have recently validated its accuracy and utility. Aherrera et al (20) used the ER French Calculator to assess the risk for in-hospital new embolic events in IE patients, using the probability on the 28th hospital day, similar to our study. They found that a probability on the 28th hospital day >7% was closely associated with the in-hospital embolic risk.…”

“…In particular, the maximum vegetation length is a major determinant of embolic events. Early surgical treatment is recommended for patients with a maximum vegetation length >10 mm, and several reports have suggested that this criterion for surgery might be associated with a risk for embolic events (14, 18-20). However, predicting embolic events using a single variable has limitations.…”