Background: Infective endocarditis (IE) affects up to 20,000 people per year in the United States. Stroke is a feared complication of IE and is associated with high morbidity and mortality. We aim to identify predictors of stroke in a large sample of patients treated at a tertiary care center.
Methods: A retrospective chart review was carried out using ICD9 codes for IE and cerebrovascular events in patients admitted to the New York Presbyterian Hospital/Columbia University Medical Center from 2000 to 2015. Incident stroke was ascertained if imaging demonstrated an acute infarction during the hospital visit in which endocarditis was diagnosed using Duke’s criteria. Demographics, vascular risks and ancillary data were obtained by chart review. Generalized linear models were used to obtain the risk ratio (RR) and their 95% confidence intervals (95%CI) adjusting for age, sex, ethnicity, hypertension, diabetes, dyslipidemia, smoking, congestive heart failure (CHF), presence of cardiac vegetations, valvular abscesses, positive blood culture, and immunosuppression.
Results: The sample included 727 IE subjects (mean age 61±18, range 18-101, 62% men, 62% non-white). Twelve percent of the sample were immunosuppressed. The majority of the patient had vegetations (61%) and positive blood cultures (87%, MRSA 13%) while valvular abscess were less frequent (13%). Of the 727 patients, 13% had an acute pre-surgical stroke (10% ischemic and 3% hemorrhagic). Meanwhile, of the 314 patient who underwent surgical intervention, only 0.5% had post-surgical strokes. The risk of pre-operative ischemic stroke was higher among patients with diabetes (RR 1.7, 1.1-2.8), cardiac vegetations (RR 2.8, 1.6-5.0), and history of prior stroke (RR 1.8, 1.8-2.9) while the risk of pre-surgical hemorrhagic stroke was higher among patients with history of prior stroke (RR 4.5, 1.7-11.9).
Conclusions: Prior stroke was a risk factor for ischemic and hemorrhagic stroke, which suggests baseline brain vulnerability that may influence the risk of stroke in the setting of IE. Additionally, diabetes and the presence of vegetations increased the risk of ischemic stroke. Early identification of sub-populations with IE at risk of stroke may help stratify risk and test preventive interventions.