Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Department of Infectious Disease, Cleveland Clinic, Cleveland, Ohio.
JAMA Intern Med. 2018 Apr 1;178(4):502-510. doi: 10.1001/jamainternmed.2017.8653.
Infective endocarditis is a life-threating condition with annual mortality of as much as 40% and is associated with embolic events in as many as 80% of cases. These embolic events have notable prognostic implications and have been linked to increased length of stay in intensive care units and mortality. A vegetation size greater than 10 mm has often been suggested as an optimal cutoff to estimate the risk of embolism, but the evidence is based largely on small observational studies.
To study the association of vegetation size greater than 10 mm with embolic events using meta-analytic techniques.
A computerized literature search of all publications in the PubMed and EMBASE databases from inception to May 1, 2017, was performed with search terms including varying combinations of infective endocarditis, emboli, vegetation size, pulmonary infarct, stroke, splenic emboli, renal emboli, retinal emboli, and mesenteric emboli. This search was last assessed as being up to date on May 1, 2017.
Observational studies or randomized clinical trials that evaluated the association of vegetation size greater than 10 mm with embolic events in adult patients with infective endocarditis were included. Conference abstracts and non-English language literature were excluded. The search was conducted by 2 independent reviewers blinded to the other's work.
Following PRISMA guidelines, the 2 reviewers independently extracted data; disputes were resolved with consensus or by a third investigator. Categorical dichotomous data were summarized across treatment arms using Mantel-Haenszel odds ratios (ORs) with 95% CIs. Heterogeneity of effects was evaluated using the Higgins I2 statistic.
The search yielded 21 unique studies published from 1983 to 2016 with a total of 6646 unique patients with infective endocarditis and 5116 vegetations with available dimensions. Patients with a vegetation size greater than 10 mm had increased odds of embolic events (OR, 2.28; 95% CI, 1.71-3.05; P < .001) and mortality (OR, 1.63; 95% CI, 1.13-2.35; P = .009) compared with those with a vegetation size less than 10 mm.
In this meta-analysis of 21 studies, patients with vegetation size greater than 10 mm had significantly increased odds of embolism and mortality. Understanding the risk of embolization will allow clinicians to adequately risk stratify patients and will also help facilitate discussions regarding surgery in patients with a vegetation size greater than 10 mm.
感染性心内膜炎是一种危及生命的疾病，其年死亡率高达 40%，并且在多达 80%的病例中与栓塞事件相关。这些栓塞事件具有显著的预后意义，并与重症监护病房住院时间延长和死亡率增加有关。大于 10 毫米的赘生物大小通常被认为是估计栓塞风险的最佳截止值，但证据主要基于小型观察性研究。
使用荟萃分析技术研究赘生物大小大于 10 毫米与栓塞事件之间的关联。
对 PubMed 和 EMBASE 数据库中从成立到 2017 年 5 月 1 日的所有出版物进行了计算机检索，检索词包括感染性心内膜炎、栓塞、赘生物大小、肺梗死、中风、脾栓塞、肾栓塞、视网膜栓塞和肠系膜栓塞的各种组合。该搜索最后一次评估日期为 2017 年 5 月 1 日。
纳入了评估成人感染性心内膜炎患者中赘生物大小大于 10 毫米与栓塞事件之间关联的观察性研究或随机临床试验。会议摘要和非英语文献被排除在外。由两名独立的审查员进行搜索，他们对彼此的工作不知情。
根据 PRISMA 指南，两名审查员独立提取数据；如有争议，通过共识或由第三名研究员解决。使用 Mantel-Haenszel 比值比 (OR) 及其 95%置信区间，对治疗组的分类二项式数据进行汇总。使用 Higgins I2 统计量评估效应异质性。
搜索结果为 1983 年至 2016 年发表的 21 项研究，共有 6646 名患有感染性心内膜炎的独特患者和 5116 个可提供尺寸的赘生物。赘生物大小大于 10 毫米的患者发生栓塞事件（OR，2.28；95%CI，1.71-3.05；P<0.001）和死亡率（OR，1.63；95%CI，1.13-2.35；P=0.009）的几率均高于赘生物大小小于 10 毫米的患者。
在这项对 21 项研究的荟萃分析中，赘生物大小大于 10 毫米的患者发生栓塞和死亡的几率显著增加。了解栓塞风险将使临床医生能够充分对患者进行风险分层，也将有助于讨论对赘生物大小大于 10 毫米的患者进行手术。
