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Infective endocarditis in Portugal: Changing epidemiology but still a deadly disease

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Infective endocarditis in Portugal: Changing

epidemiology but still a deadly disease

Gilbert Habib

To cite this version:

Gilbert Habib. Infective endocarditis in Portugal: Changing epidemiology but still a deadly

dis-ease. Revista Portuguesa de Cardiología, Elsevier España (Elsevier Doyma), 2021, 40 (3), pp.219-220.

�10.1016/j.repc.2021.01.006�. �hal-03243252�

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RevistaPortuguesadeCardiologia40(2021)219---220

www.revportcardiol.org

Revista

Portuguesa

de

Cardiologia

Portuguese

Journal

of

Cardiology

EDITORIAL

COMMENT

Infective

endocarditis

in

Portugal:

Changing

epidemiology

but

still

a

deadly

disease

Endocardite

infeciosa

em

Portugal:

uma

epidemiologia

em

evoluc

¸ão,

mas

ainda

uma

doenc

¸a

mortal

Gilbert

Habib

a,b

aAPHM,LaTimoneHospital,CardiologyDepartment,Marseille,France

bAixMarseilleUniv,IRD,APHM,MEPHI,IHU-MéditerranéeInfection,Marseille,France

Availableonline1March2021

Infectiveendocarditis(IE)isaseverediseaseassociatedwith

high morbidity and mortality1---5 and whose incidence and

severityremain unchangeddespite improvements in diag-nosticandtherapeuticstrategies.Themainreasonforthis apparentunchangedprognosisisbecauseIEisachanging dis-ease,witholderpatientswithmoreseveredisease,changing epidemiological profiles and greater numbers of patients withprostheticvalveordevice-relatedinfections.5,6

Diagnostic strategies and management may differ

between countries and these differences are currently investigated in the EURO-ENDO registry,7 which

prospec-tivelyincluded3116adultpatients(2470fromEurope,646 fromnon-EuropeanSociety ofCardiology(ESC)countries), admittedto156hospitalsin40countriesbetweenJanuary 2016 and March2018 witha diagnosis of IEbased onESC 2015diagnosticcriteria.8

InthisissueofthePortugueseJournalofCardiology,de Sousaetal.9 present a systematicreview of allpublished

seriesofpatientshospitalizedwithIEinPortuguesehospital centers.

E-mailaddress:gilbert.habib3@gmail.com

This reviewgivesustheopportunity tocomparetheIE characteristicsobservedinPortugaltothoseofIEcurrently observedinotherpartsoftheworld,asreportedinEuropean InfectiveEndocarditisRegistry(EURO-ENDO).7

Epidemiology

of

infective

endocarditis

IntheseriesbydeSousaetal.,9themeanageofpatientswas

55.5±12.1years,withalargepredominanceofmales.This populationisyoungerthanthatobservedinEURO-ENDOand thismayberelatedtothehighnumberofintravenousdrug usersandtotheinclusionofsomerelativelyoldstudieswith possibly younger patients. In three one-year population-based surveys conducted in 1991, 1999, and 2008,5,6 the

totalIEincidenceremainedstableovertime,butmeanage progressivelyincreasedfrom57.9 ±16.6 yearsin1991 to 61.6±16.3yearsin2008.Similarly,theincidenceofcardiac device-relatedIE(CDRIE) isincreasing. Althoughobserved in only 6.1% of cases in the Portuguese series, it is now muchmorefrequent (9.9%)inEURO-ENDO,7reflectingthe

increasingburdenofIEinthisolderpopulation.Conversely, the relatively high incidence of enterococci (11.7 to 15% ofpatients)reportedbythecurrentstudycorroboratesthe currentincreasingincidenceofthismicroorganism(15.8%)

https://doi.org/10.1016/j.repc.2021.01.006

0870-2551/©2021SociedadePortuguesadeCardiologia.PublishedbyElsevierEspa˜na,S.L.U.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

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G.Habib reportedinEURO-ENDO,againreflectingtheincreasingage ofthispopulation.

Imaging

One of the most important changes in the diagnosis of IE is the implementation of non-echocardiographic imag-ingtechniques,mainlycardiaccomputedtomography(CT) and 18F-fluorodeoxyglucose positron emission tomography

/computedtomography(18F-FDGPET/CT).8,10 These

tech-niquesaremoreandmorefrequentlyusedinIE,particularly inthefieldofsuspectedprostheticvalveIE.Forinstance, [18F]FDG PET/CT was performed in 16.6% of patients in

EURO-ENDO(7),andmultisliceCTin53.1%ofpatients.The low use of thesetechniques in Portuguese centers proba-blyreflectsthedifficultaccesstonuclearimaginginsome Portuguesecities.Butmoreimportantly,asreportedbythe authors, themain explanation is theinclusion of patients beforethepublicationofthe2015ESCguidelines,8inwhich

thesenewimagingtoolswereincludedforthefirsttimein thediagnosticandprognosticstratificationofIE. Neverthe-less, the use of [18F]FDG PET/CT varied largely between countriesacrosstheworld,rangingfrom0.5to33.9%ofIE casesinEURO-ENDO.7

Treatment

and

prognosis

in

infective

endocarditis

At Portuguese centers, the reported surgical rate ranged from 3.1 to 52%, with a trend toward a higher surgical rateinthemostrecentseries,withthreemainindications forsurgery:heartfailure(50and74%),uncontrolled infec-tion (27.3and 46.8%) andembolization (13.6 and 15.6%). TheseresultssupportcurrentESCguidelines,8inwhichearly

surgery is recommended as soon as one of these three complication occurs. In EURO-ENDO,7 we focused on the

implementation of the ESC guidelines in clinical practice and found that, although theoretical indication for car-diac surgery was present in 69.3% patients, surgery was eventually performed during hospitalization in only 51.2% patients. Failure to perform surgery when indicated was associatedwiththeworstprognosisinEURO-ENDO, empha-sizingthebenefitofanaggressivesurgicalstrategyinthese patients.Therelativelyhighin-hospitalandlong-term mor-talityreportedatPortuguesecentersprobablyreflectsthe lowuse ofsurgery(29.8%)in somerelativelyoldreported series.

Conclusion

and

perspectives

The report fromde Sousa et al. (9), although limited by its retrospective nature and other issues reported by the

authors,has themerit ofemphasizing themain messages ofEURO-ENDO,includingthehigherfrequencyofIEamong theelderly,inprostheticIEandinCDRIE,thevalueofnew imagingtechniques,stillunderusedinseveralcountries,the needforearlysurgicalmanagement,andthestillpoor prog-nosisofIE,particularlywhensurgeryisindicatedandcannot beperformed.Endocarditisteams8arenowinexistenceat

severalhospitalsacrossEurope.Theywillhelpimplementing theESCguidelinesinthefuture,bothintermsofdiagnostic andtherapeuticstrategies,andimprovingtheprognosisof thisdevastatingdisease.

Conflicts

of

interest

Theauthorshavenoconflictsofinteresttodeclare.

References

1.Habib G, Salaun E, Hubert S. Infective endocarditis: a deadlydiseaseifdiagnosedtoolate.JAmSocEchocardiogr. 2016;29:323---4.

2.Habib G. Management of infective endocarditis. Heart. 2006;92:124---30.

3.Chu VH, Cabell CH, Benjamin DK Jr, et al. Early predic-torsofin-hospitaldeathininfectiveendocarditis.Circulation. 2004;109:1745---9.

4.SanRomanJA,LopezJ,VilacostaI,etal.Prognostic stratifi-cationofpatientswithleft-sidedendocarditisdeterminedat admission.AmJMed.2007;120:369---77.

5.HoenB,AllaF,Selton-SutyC,etal.Changingprofileof infec-tiveendocarditis:resultsofa1-yearsurveyinFrance.JAMA. 2002;288:75---81.

6.Selton-Suty C 1,Célard M, LeMoing V, et al. Pre-eminence of Staphylococcus aureus ininfective endocarditis: a 1-year population-basedsurvey.ClinInfectDis.2012;54:1230---9. 7.Habib G, Erba PA,Iung B, et al. Clinicalpresentation,

aeti-ology and outcome of infective endocarditis. Results of the ESC-EORP EURO-ENDO(European infective endocarditis) reg-istry:aprospectivecohortstudy.EurHeartJ.2019;40:3222---32. 8.HabibG,LancellottiP,AntunesMJ,etal.ESCScientific Doc-ument Group, 2015 ESC Guidelines for the management of infectiveendocarditis:TheTaskForcefortheManagementof Infective Endocarditis ofthe EuropeanSocietyof Cardiology (ESC).EurHeartJ.2015;36:3075---128.

9.deSousaC,RibeiroRM,PintoF.Theburdenofinfective endo-carditisinPortugalinthelast30years---asystematicreviewof observationalstudies.RevPortCardiol.2021;40:205---17. 10.SabyL, Laas O, HabibG, et al. F.Positron emission

tomog-raphy/computedtomographyfordiagnosisofprostheticvalve endocarditis:Increasedvalvular18F-fluorodeoxyglucoseuptake asanovelmajorcriterion.JAmCollCardiol.2013;61:2374---82.

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