Effect of antithrombotic therapy on mortality and neurologic outcome in patients with left sided infective endocarditis

https://doi.org/10.1007/s00392-025-02625-4

Carlotta Posner (Regensburg)1, F. Koyun (Regensburg)1, E. Füssl (Regensburg)1, M. Upsing (Regensburg)1, F. Hitzenbichler (Regensburg)2, L. S. Maier (Regensburg)1, K. Debl (Regensburg)1, F. Schlachetzki (Regensburg)3, C. Schach (Regensburg)1

1Universitätsklinikum Regensburg Klinik und Poliklinik für Innere Med. II, Kardiologie Regensburg, Deutschland; 2Krankenhaushygiene und Infektiologie Regensburg, Deutschland; 3Klinik für Neurologie Regensburg, Deutschland

 

Background: Antithrombotic therapy (ATT) in patients with infective endocarditis (IE) remains a matter of compromise. Evidence on mid- and long-term outcomes is limited. This study aims to evaluate the effect of ATT on mortality and functional neurological outcome in patients with left-sided IE.

Methods: We retrospectively analyzed data in a tertiary care hospital for IE cases over 10 years. Further, vital and neurological status (modified Ranking Scale, mRS) were assessed by a telephone follow-up. Endpoints were all-cause mortality and unfavorable neurological outcome (mRS score ≥3 out of 5 points). Survival and regression analyses were employed to estimate the effect of ATT. As ATT has changed during hospitalization for some patients, two cohorts were analyzed: the intra-hospital cohort was based on ATT at admission (adm-ATT), and the extra-hospital cohort (consisting of the same patients as the first cohort minus those who died in hospital) was based on ATT at discharge (dis-ATT).


Results: 367 consecutive patients (65 ± 13 years, 25% female) with left -sided IE were analyzed. Mean follow-up time was 4.0 ± 3.3 years. At admission, 182 patients (49.6%) received no ATT (none), 104 (28.3%) received mono or dual antiplatelet therapy (ATP), and 81 (22.1%) were on anticoagulation (AC) with or without ATP. During the hospital stay (36 ± 33 days), 74 patients died, 16.5% without adm-ATT, 23.1% with ATP, and 24.7% with AC (P = 0.212, 1-way ANOVA). 297 patients were discharged, 61 (20.8%) without ATT, 45 (15.4%) with ATP, and 188 (64.2%) with AC. Until follow-up (mean 4.0 ± 3.3 years) Kaplan-Meier survival analysis (Figures 1A and B) showed no significant difference for intra- (P = 0.549) and extra-hospital (0.077) mortality. Interestingly, Cox regression analysis revealed an influence of adm-ATT (estimate 1.70, 95% confidence interval 1.20-2.42) as well as dis-ATT (0.48, 0.37-0.67), indicating a higher intra-hospital and a lower extra-hospital mortality with ATT. See Table 1, also for other explanatory variables. Unfavorable neurological outcome occurred in 31.1% without ATT, 28.3 % with ATP and 32.3 % with AC (P = 0.920) with no explanatory effect of adm-ATT (1.38, 0.59-3.07, P = 0.433) or dis-ATT (0.64, 0.33-1.27, P = 0.169) in the Cox regression model.


Conclusion: In this retrospective analysis we were able to add evidence on the effect of ATT on mortality and neurologic outcome in patients hospitalized for left-sided IE. While there was no significant difference in survival analysis between the 3 ATT groups on intra- and extra-hospital mortality, ATT at admission was associated with an increased hazard ratio for intra-hospital mortality and a decreased hazard ratio for extra-hospital mortality. Unfavorable neurological outcome did not differ between the groups.




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