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Caldonazo T, Musleh R, Moschovas A, Kirov H, Franz M, Haeusler KG, Faerber G, Doenst T, Günther A, Diab M. Antithrombotic Therapy in Patients With Infective Endocarditis: A Systematic Review and Meta-Analysis. JACC. ADVANCES 2024; 3:100768. [PMID: 38939390 PMCID: PMC11198087 DOI: 10.1016/j.jacadv.2023.100768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/03/2023] [Accepted: 10/20/2023] [Indexed: 06/29/2024]
Abstract
Background Antithrombotic therapy (ATT) in patients with infective endocarditis (IE) is challenging. Objectives The authors evaluated the impact of anticoagulant and antiplatelet therapy on clinical endpoints in IE patients. Methods We performed a systematic review and meta-analysis comparing IE patients with prior and/or ongoing use of ATT vs those without any ATT during IE course. Primary outcome was reported in-hospital cerebrovascular events. Secondary outcomes were in-hospital mortality, intracranial hemorrhage (ICH), systemic thromboembolism (ST), and mortality within 6 months. Results Twelve studies, with a total of 12,151 patients, were included. The primary endpoint was not different comparing 10,115 IE patients with or without prior anticoagulation (OR: 1.10; 95% CI: 0.56-2.17; P = 0.77) or comparing 838 IE patients with or without prior antiplatelet (OR: 0.90; 95% CI: 0.61-1.33; P = 0.61). In-hospital mortality was lower in IE patients with prior anticoagulation compared to those without (OR: 0.74; 95% CI: 0.57-0.96; P = 0.03). There was no difference in reported ICH rates between patients with or without prior anticoagulation (OR: 0.54; 95% CI: 0.27-1.09; P = 0.09) or between patients with or without prior antiplatelet (OR: 0.35; 95% CI: 0.11-1.10; P = 0.07). The rate of ST was lower in IE patients with prior antiplatelet therapy compared to those without (OR: 0.53; 95% CI: 0.38-0.72; P < 0.01). Conclusions ATT in IE patients was not associated with higher frequency of cerebrovascular events or ICH. Moreover, we found that the use of anticoagulation was associated with decreased in-hospital mortality and the use of antiplatelets was associated with decreased ST. Due to the limitations of this study, these results should be interpreted cautiously showing the necessity of a randomized setup.
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Affiliation(s)
- Tulio Caldonazo
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University, Jena, Germany
| | - Rita Musleh
- Department of Neurology, Friedrich-Schiller-University, Jena, Germany
| | - Alexandros Moschovas
- Department of Thoracic and Cardiovascular Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Hristo Kirov
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University, Jena, Germany
| | - Marcus Franz
- Department of Cardiology, Friedrich-Schiller-University, Jena, Germany
| | - Karl Georg Haeusler
- Department of Neurology, University Hospital of Würzburg (UKW), Würzburg, Germany
| | - Gloria Faerber
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University, Jena, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University, Jena, Germany
| | - Albrecht Günther
- Department of Neurology, Friedrich-Schiller-University, Jena, Germany
| | - Mahmoud Diab
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University, Jena, Germany
- Department of Cardiac Surgery, Herz-und Kreislaufzentrum, Rotenburg an der Fulda, Germany
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Lee TTL, Chan SCL, Chou OHI, Lee S, Chan JSK, Liu T, Chang C, Wong WT, Lip GYH, Cheung BMY, Wai AKC, Tse G. Initiation of warfarin is associated with decreased mortality in patients with infective endocarditis: A population-based cohort study. Thromb Res 2024; 233:1-9. [PMID: 37979284 DOI: 10.1016/j.thromres.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/20/2023]
Abstract
IMPORTANCE The use of warfarin to prevent thromboembolism in patients with infective endocarditis (IE) remains controversial due to potentially increased bleeding risks. DESIGN Population-based retrospective cohort study. PARTICIPANTS Patients aged 18 or older and diagnosed with IE in Hong Kong between January 1st, 1997 and August 31st, 2020 were included. Patients with use of any anticoagulant 30 days before IE diagnosis were excluded. Patients initiated on warfarin within 14 days of IE diagnosis and patients without warfarin use were matched for baseline characteristics using 1:1 propensity score matching. EXPOSURE Warfarin use within 14 days of IE diagnosis. MAIN OUTCOMES AND MEASURES Patients were followed up to 90 days for the outcomes of ischemic stroke, all-cause mortality, intracranial hemorrhage, and gastrointestinal bleeding. Cox regression was used to determine hazard ratios (HRs) [95 % confidence intervals (CIs)] between treatment groups. Fine-Gray competing risk regression with all-cause mortality as the competing event was performed as a sensitivity analysis. In addition to 90-day analyses, landmark analyses were performed at 30 days of follow-up. RESULTS The matched cohort consisted of 675 warfarin users (57.0 % male, age 59 ± 16 years) and 675 warfarin non-users (53.5 % male, age 61 ± 19 years). Warfarin users had a 50 % decreased 90-day risk in all-cause mortality (HR:0.50 [0.39-0.65]), without significantly different 90-day risks of ischemic stroke (HR:1.04 [0.70-1.53]), intracranial hemorrhage (HR:1.25 [0.77-2.04]), and gastrointestinal bleeding (HR:1.04 [0.60-1.78]). Thirty-day landmark analysis showed similar results. Competing risk regression showed significantly higher 30-day cumulative incidence of intracranial hemorrhage in warfarin users (sub-HR:3.34 [1.34-8.31]), but not at 90-day (sub-HR:1.63 [0.95-2.81]). Results from Fine-Gray regression were otherwise congruent with those from Cox regression. CONCLUSIONS AND RELEVANCE Warfarin initiated within 14 days of IE diagnosis was associated with significantly decreased risks of mortality but higher risks of intracranial hemorrhage, with similar risks of ischemic stroke and gastrointestinal bleeding, compared with non-use of warfarin with 14 days of IE diagnosis. KEY POINTS Question: Is warfarin, initiated within 14 days of a diagnosis of infective endocarditis (IE), efficacious and safe? FINDINGS In this propensity score-matched, population-based, prospective cohort study from Hong Kong, warfarin use within 14 days of IE diagnosis was associated with a 50 % decrease in the risk of all-cause mortality, albeit with higher risk of intracranial hemorrhage, and without significant differences in the risk of ischaemic stroke and gastrointestinal bleeding. Meaning: In patients with IE, warfarin use within 14 days of diagnosis may have mortality benefits, despite increased risks of intracranial hemorrhage.
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Affiliation(s)
- Teddy Tai Loy Lee
- Department of Emergency Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, China; Cardiovascular Pharmacology Unit, Cardiovascular Analytics Group, PowerHealth Research Institute, Hong Kong, China.
| | - Sunny Ching Long Chan
- Department of Emergency Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, China.
| | - Oscar Hou In Chou
- Cardiovascular Pharmacology Unit, Cardiovascular Analytics Group, PowerHealth Research Institute, Hong Kong, China; Division of Clinical Pharmacology, School of Clinical Medicine, The University of Hong Kong, Hong Kong, China.
| | - Sharen Lee
- Cardiovascular Pharmacology Unit, Cardiovascular Analytics Group, PowerHealth Research Institute, Hong Kong, China.
| | - Jeffrey Shi Kai Chan
- Cardiovascular Pharmacology Unit, Cardiovascular Analytics Group, PowerHealth Research Institute, Hong Kong, China.
| | - Tong Liu
- Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin 300211, China.
| | - Carlin Chang
- Division of Neurology, Department of Medicine, Queen Mary Hospital and The University of Hong Kong, Hong Kong, China.
| | - Wing Tak Wong
- State Key Laboratory of Agrobiotechnology (CUHK), School of Life Sciences, The Chinese University of Hong Kong, Hong Kong, China.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Bernard Man Yung Cheung
- Division of Clinical Pharmacology, School of Clinical Medicine, The University of Hong Kong, Hong Kong, China.
| | - Abraham Ka-Chung Wai
- Department of Emergency Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, China.
| | - Gary Tse
- Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin 300211, China; Kent and Medway Medical School, University of Kent and Canterbury Christ Church University, Canterbury, United Kingdom; School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China.
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Nitsch L, Shirvani Samani O, Silaschi M, Schafigh M, Zimmer S, Petzold GC, Kindler C, Bode FJ. Infective endocarditis and stroke: when does it bleed? A single center retrospective study. Neurol Res Pract 2023; 5:13. [PMID: 37020243 PMCID: PMC10077710 DOI: 10.1186/s42466-023-00239-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/24/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Infective endocarditis (IE) is a serious condition with a high mortality, represents a rare cause of stroke and an increased risk of intracranial hemorrhage. In this single center study, we characterize stroke patients with IE. We were interested in risk factors for intracranial hemorrhage and outcome of patients with intracranial hemorrhage compared to patients with ischemic stroke. METHODS Patients with IE and symptomatic ischemic stroke or intracranial hemorrhage admitted to our hospital between January 2019 and December 2022 were included in this retrospective study. RESULTS 48 patients with IE and ischemic stroke or intracranial hemorrhage were identified. 37 patients were diagnosed with ischemic stroke, 11 patients were diagnosed with intracranial hemorrhage. The intracranial hemorrhage occurred within the first 12 days after admission. We identified Staphylococcus aureus detection and thrombocytopenia as risk factors for hemorrhagic complications. An increased in-hospital mortality in patients with intracranial hemorrhage (63.6% vs. 22%, p = 0.022) was found, whereas patients with ischemic stroke and patients with intracranial hemorrhage do not differ regarding favorable clinical outcome (27% vs. 27.3%, p = 1.0). 27.3% patients with intracranial hemorrhage and 43.2% patients with ischemic stroke underwent cardiac surgery. Overall, 15.7% new ischemic strokes occurred after valve reconstruction, whereas no new intracranial hemorrhage was observed. CONCLUSIONS We found an increased in-hospital mortality in patients with intracranial hemorrhage. Beside thrombocytopenia, we identified S. aureus detection as a risk factor for intracranial hemorrhage.
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Affiliation(s)
- L Nitsch
- Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - O Shirvani Samani
- Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - M Silaschi
- Department of Cardiac Surgery, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - M Schafigh
- Department of Cardiac Surgery, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - S Zimmer
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - G C Petzold
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- German Center for Neurodegenerative Diseases (DZNE), Venusberg-Campus 1, 53127, Bonn, Germany
| | - C Kindler
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- German Center for Neurodegenerative Diseases (DZNE), Venusberg-Campus 1, 53127, Bonn, Germany
| | - F J Bode
- Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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Pisaryuk AS, Zamarashkina VA, Safarova NB, Povalyaev NM, Kotova EO, Babukhina UI, Koltsova EM, Kobalava ZD. Coagulation Disorders in Infective Endocarditis: Role of Pathogens, Biomarkers, Antithrombotic Therapy (Systematic Review). RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-06-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The issue of antithrombotic therapy in patients with infective endocarditis has been studied for over 75 years. During that time studying of pathogenesis of the disease and its embolic complications, lead to the introduction of the concept of “immunothrombosis”. That mechanism allows infective agents (mostly bacteria) to be cloaked from the immune system and to multiply freely, leading to growth of vegetation, thus resulting in higher chance of fragmentation. Small-scale experimental and clinical studies on the correction of hemostatic disorders in infective endocarditis, that were performed in 20th century, didn’t show any significant results, that could affect clinical practice. However, reinterpretation of available data on coagulative system will allow to have elements of hemostasis as an application point in treating infective endocarditis. The article will discuss latest insights on the role of hemostasis system in pathophysisology of infective endocarditis, its effects on the development of the embolic complications, perspectives for diagnostics and treatment.
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Affiliation(s)
- A. S. Pisaryuk
- RUDN University; Moscow City Hospital named after V.V. Vinogradov
| | | | | | | | | | | | - E. M. Koltsova
- Center for Theoretical Problems of Physicochemical Pharmacology; Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology
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Arnautu SF, Arnautu DA, Lascu A, Hajevschi AA, Rosca CII, Sharma A, Jianu DC. A Review of the Role of Transthoracic and Transesophageal Echocardiography, Computed Tomography, and Magnetic Resonance Imaging in Cardioembolic Stroke. MEDICAL SCIENCE MONITOR : INTERNATIONAL MEDICAL JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2022; 28:e936365. [PMID: 35729858 PMCID: PMC9235914 DOI: 10.12659/msm.936365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Stroke is a major source of morbidity and mortality worldwide, accounting for the second largest cause of mortality and the third greatest cause of disability. Stroke is frequently preceded by a transient ischemic attack (TIA). The etiologies of 20-30% of ischemic strokes are unknown, and thus are termed "cryptogenic strokes". About 25% of ischemic strokes are cardioembolic. Strokes occur at a rate of around 2% per year in individuals with heart failure with reduced ejection fraction (HFrEF), with a strong correlation between stroke risk and the degree of ventricular impairment. Furthermore, stroke risk is augmented in the absence of anticoagulation therapy. Cardioembolic strokes, when treated inadequately, have a greater predilection for recurrences than atherothrombotic strokes, both early and late in life. The role of a patent foramen ovale in strokes, specifically in "cryptogenic strokes", is a matter of concern that deserves due attention. The use of tissue-engineered heart valves and aspirin for minimizing the risk of stroke is recommended. Transthoracic echocardiography (TTE) is advantageous for assessing heart function in the acute phase of ischemic stroke. Transesophageal echocardiography (TEE) is considered the criterion standard procedure for detecting LAA thrombi. Computed tomography (CT) scans are good imaging modalities for identifying and excluding bleeding. Magnetic resonance imaging (MRI) images are by far the most effective imaging technique available for assessing the brain parenchymal state. We conducted a thorough review of the literature on the use of imaging modalities, highlighting the important contribution of TTE, TEE, CT, and MRI in the evaluation of cardioembolic stroke.
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Affiliation(s)
- Sergiu Florin Arnautu
- Department of Neurology, "Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania.,Department of Neurology, Clinical Emergency County Hospital, Timisoara, Romania.,Centre of the Cognitive Research in Neuropsychiatric Pathology, "Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania
| | - Diana Aurora Arnautu
- Department of Cardiology, "Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania
| | - Ana Lascu
- Department of Functional Sciences, Discipline Pathophysiology, "Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania.,Centre for Translational Research and Systems Medicine, "Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania.,Institute of Cardiovascular Diseases, Timisoara, Romania
| | - Andrei A Hajevschi
- Department of Neurology, Clinical Emergency County Hospital, Timisoara, Romania
| | - Ciprian Ilie Ilie Rosca
- Advanced Research Center for Cardiovascular Pathology and Hemostasis, Department of Internal Medicine I - Medical Semiology I, "Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania.,Department of Internal Medicine, Municipal Emergency University Hospital, Timisoara, Romania.,Family Physician Clinic, Civil Medical Society Dr Rosca, Teremia Mare, Timis, Romania
| | - Abhinav Sharma
- Department of Cardiology, "Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania.,Family Physician Clinic, Civil Medical Society Dr Rosca, Teremia Mare, Timis, Romania.,Department of Occupational Medicine, Municipal Emergency University Hospital, Arad, Romania
| | - Dragos Catalin Jianu
- Department of Neurology, "Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania.,Department of Neurology, Clinical Emergency County Hospital, Timisoara, Romania.,Centre of the Cognitive Research in Neuropsychiatric Pathology, "Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania
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Antiplatelet Therapy in Staphylococcus aureus Bacteremia: No Time Like the Past? Antimicrob Agents Chemother 2022; 66:e0036522. [PMID: 35535570 DOI: 10.1128/aac.00365-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In this invited commentary, we reflect on the accompanying study by A. R. Caffrey, H. J. Appaneal, K. L. LaPlante, V. V. Lopes, et al. (Antimicrob Agents Chemother 66:e02117-21, 2022, https://doi.org/10.1128/aac.02117-21), which analyzed the impact of clopidogrel use on clinical outcomes in Staphylococcus aureus bacteremia.
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