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Primus C, Bvekerwa I, McCue M, Menezes L, Serafino-Wani R, Das S, Wong K, Uppal R, Ambekar S, Bhatacharyya S, Woldman S, Davies L. The impact of frailty in an endocarditis cohort: association with length of stay and mortality. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Predictors of poor outcome are well established in Endocarditis (IE). “Frailty” refers to a syndrome of physiological decline associated with adverse health outcomes. Gilbert et al.(Lancet, 2018) developed a Hospital Frailty Risk Score (HFRS) that predicts 30-day mortality and length of stay (LOS).
Aim
Identify impact of an abbreviated HFRS (aHFRS) on in-hospital survival and LOS in IE given high morbidity and mortality.
Methods
Retrospective analysis of prospectively collected cases (Jan 2018–date). aHFRS score was calculated with key IE, cardiac, respiratory, oncology & frailty diagnoses. Univariate regression was applied overall and in key “cohorts” (native & prosthetic IE, medical & surgical management) for survival and LOS.
Results
Of 334 cases, LOS data were available in 317; mean age 57.8y (range 17–91, male 74%). Table 1 describes key cohorts. Mortality was 10.1% (medical, 11.9%; surgical, 8.3%). Mean LOS was 31.2 days (range 0–224).
Mean aHFRS was 5.38diagnoses (SD 2.61, range 0–14); 1.65 pre-IE and 3.73 attributed to IE alone, consistent across cohorts. Regression analyses highlight increasing LOS with increasing aHFRS (r2=0.06, Figure 1). Table 1 summarises the modest impact of aHFRS on LOS, and a trend to worse outcome in medical management (r2=0.02).
Discussion
Higher aHFRS is associated with longer LOS and a trend to higher mortality in medically managed IE. IE itself is associated with a number of frailty diagnoses. To improve outlook and provide holistic care, the IE Team may need to include experts in frailty. Satisfactory outcomes may require intensive post-IE rehabilitation.
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- C.P Primus
- Barts Heart Centre & Queen Mary, University of London, London, United Kingdom
| | - I Bvekerwa
- Barts Heart Centre, London, United Kingdom
| | - M McCue
- Barts Heart Centre, London, United Kingdom
| | - L Menezes
- Barts Heart Centre, London, United Kingdom
| | | | - S Das
- Barts Heart Centre & Queen Mary, University of London, London, United Kingdom
| | - K Wong
- Barts Heart Centre, London, United Kingdom
| | - R Uppal
- Barts Heart Centre & Queen Mary, University of London, London, United Kingdom
| | - S Ambekar
- Barts Heart Centre, London, United Kingdom
| | | | - S Woldman
- Barts Heart Centre, London, United Kingdom
| | - L.C Davies
- Barts Heart Centre, London, United Kingdom
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Primus CP, McCue M, Bvekerwa I, McGuire E, Wong K, Uppal R, Ambekar S, Menezes L, Khanji M, Davies LC, Bhattacharyya S, Serafino-Wani R, Das S, Woldman S. P2764Medical management of Staphylococcus aureus infective endocarditis: unexpectedly favourable outcomes in an aggressive disease. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.1081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Early surgical intervention (ESI) for infective endocarditis (IE) is associated with improved outcomes. Staphylococcus aureus endocarditis (SAE) is associated with particularly high rates of tissue destruction, morbidity and mortality. However, the question as to whether ESI is mandated in all SAE continues to be debated, in both native (NVE) and prosthetic (PVE) endocarditis.
Methods
Retrospective review of all IE cases presenting to our institution from October 2015 to January 2019. IE was diagnosed following imaging and microbiological protocols as per ESC guidance, and data were extracted for those with SAE. Patients with isolated cardiac implantable electronic device IE or bacteraemia secondary to indwelling long-term venous catheter infection were excluded (non-valvular IE).
Results
Valvular IE was diagnosed in 411 patients overall; NVE in 286 (69.6%) and PVE in 125 (30.4%). S aureus was isolated in 111 patients (28.1%), of whom 5 had a Methicillin-resistant strain. SAE was confirmed in a similar proportion of NVE and PVE cases [83/111 (74.8%) and 28/111 (25.2%), respectively]. Surgical intervention was mandated in 35/83 with NVE (42.2%) and 11/28 (39.3%) with PVE, lower than in our overall cohort (55.9% and 48.8%, respectively).
In-hospital SAE mortality was 16.2% overall (18.4% medical vs 13.0% surgical), and contributes a significant proportion to overall mortality (29% to medical & 26% to surgical mortality). Figure 1 identifies the cause of death per mode of treatment, highlighting the aggressive nature of S aureus infection (abscess, disseminated infection and septic shock; n=8), the importance of advanced non-cardiac comorbidity precluding intervention (n=3) and ongoing intravenous drug use in those with PVE (n=4). However, medical management was successful in 57.8% (38/83) of NVE and 60.7% (17/28) of PVE cases, both in hospital and to a minimum follow-up of 3-months.
Conclusion
Staphylococcus aureus is virulent and highly pathogenic, driving severe sepsis and advanced tissue destruction in SAE. Despite this, medical management can be successful when following international guidance, but requires co-ordinated care driven by a multidisciplinary IE team at a cardiothoracic centre.
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Affiliation(s)
- C P Primus
- Barts Heart Centre & Queen Mary, University of London, London, United Kingdom
| | - M McCue
- Barts Heart Centre, London, United Kingdom
| | - I Bvekerwa
- Barts Heart Centre, London, United Kingdom
| | - E McGuire
- Barts Heart Centre, London, United Kingdom
| | - K Wong
- Barts Heart Centre, London, United Kingdom
| | - R Uppal
- Barts Heart Centre & Queen Mary, University of London, London, United Kingdom
| | - S Ambekar
- Barts Heart Centre & Queen Mary, University of London, London, United Kingdom
| | - L Menezes
- Barts Heart Centre, London, United Kingdom
| | - M Khanji
- Barts Heart Centre, London, United Kingdom
| | - L C Davies
- Barts Heart Centre & Queen Mary, University of London, London, United Kingdom
| | | | | | - S Das
- Barts Heart Centre & Queen Mary, University of London, London, United Kingdom
| | - S Woldman
- Barts Heart Centre, London, United Kingdom
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Primus CP, Clay T, Al-Khayfawee A, Scully PR, Wong K, Uppal R, Das S, Serafino-Wani R, Bhattacharyya S, Davies LC, Woldman S, Menezes L. 19718F-FDG PET/CT improves diagnostic certainty in native and prosthetic valve infective endocarditis over the modified Duke"s criteria. Eur Heart J Cardiovasc Imaging 2019. [DOI: 10.1093/ehjci/jez144.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- C P Primus
- Barts Heart Centre & Queen Mary, University of London, London, United Kingdom of Great Britain & Northern Ireland
| | - T Clay
- University College London, London, United Kingdom of Great Britain & Northern Ireland
| | - A Al-Khayfawee
- University College London Hospitals, London, United Kingdom of Great Britain & Northern Ireland
| | - P R Scully
- University College London, London, United Kingdom of Great Britain & Northern Ireland
| | - K Wong
- Barts Heart Centre, London, United Kingdom of Great Britain & Northern Ireland
| | - R Uppal
- Barts Heart Centre & Queen Mary, University of London, London, United Kingdom of Great Britain & Northern Ireland
| | - S Das
- Barts Heart Centre & Queen Mary, University of London, London, United Kingdom of Great Britain & Northern Ireland
| | - R Serafino-Wani
- Barts Heart Centre, London, United Kingdom of Great Britain & Northern Ireland
| | - S Bhattacharyya
- Barts Heart Centre, London, United Kingdom of Great Britain & Northern Ireland
| | - L C Davies
- Barts Heart Centre & Queen Mary, University of London, London, United Kingdom of Great Britain & Northern Ireland
| | - S Woldman
- Barts Heart Centre & Queen Mary, University of London, London, United Kingdom of Great Britain & Northern Ireland
| | - L Menezes
- Barts Heart Centre, London, United Kingdom of Great Britain & Northern Ireland
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