Faculty of Medicine, University of Toronto, Toronto, Canada.
Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada.
Clin Microbiol Infect. 2019 Feb;25(2):178-187. doi: 10.1016/j.cmi.2018.08.010. Epub 2018 Aug 24.
Prediction of embolic events (EEs) in infective endocarditis (IE) could inform clinical decisions, such as surgical timing. We conducted a systematic review to more precisely define associations between risk factors and EEs.
We searched two bibliographic databases (1994-2018) for observational studies that reported EEs in IE patients and considered clinical, microbiological or echocardiographic risk factors. Studies that did not use Duke criteria or only investigated a subset of IE patients were excluded. Study quality was assessed using the Newcastle-Ottawa scale. A pooled risk ratio (RR) for each risk factor was estimated using random-effects models; statistical heterogeneity was estimated using I.
Of 3862 unique citations, 47 cohort studies (11 215 IE cases) were included; 54 risk factors were analysed in at least two studies, with nine studies reporting other individual factors. Most studies were of high methodological quality. Major predictors of EEs were intravenous drug use (RR 1.69, 95% CI 1.32-2.17; I = 46%), Staphylococcus aureus infection (RR 1.64, 95% CI 1.45-1.86, I = 32%), mitral valve vegetation (RR 1.24, 95% CI 1.11-1.37, I = 30%), and vegetation size >10 mm (RR 1.87, 95% CI 1.57-2.21, I = 48%). EE risk was also higher with human immunodeficiency virus, chronic liver disease, elevated C-reactive protein, Staphylococcus spp. infection, vegetation presence, and multiple, mobile or prosthetic mechanical valve vegetation, and lower with Streptococcus spp. infection. Most findings were unchanged in sensitivity analyses that removed studies with pulmonary EEs from the outcome.
Given the serious consequences of embolism, surgical evaluation may be considered in patients with these risk factors.
感染性心内膜炎（IE）中栓塞事件（EEs）的预测可以为临床决策提供信息，例如手术时机。我们进行了一项系统评价，以更准确地定义危险因素与 EEs 之间的关联。
我们在两个文献数据库（1994-2018 年）中搜索了报告 IE 患者 EEs 的观察性研究，并考虑了临床、微生物学或超声心动图危险因素。未使用 Duke 标准或仅调查 IE 患者亚组的研究被排除在外。使用纽卡斯尔-渥太华量表评估研究质量。使用随机效应模型估计每个危险因素的合并风险比（RR）；使用 I 估计统计异质性。
在 3862 个独特的引文，47 项队列研究（11215 例 IE 病例）被纳入；至少有两项研究分析了 54 个危险因素，有九项研究报告了其他个别因素。大多数研究的方法学质量较高。EEs 的主要预测因素是静脉内药物使用（RR 1.69，95%CI 1.32-2.17；I = 46%）、金黄色葡萄球菌感染（RR 1.64，95%CI 1.45-1.86，I = 32%）、二尖瓣赘生物（RR 1.24，95%CI 1.11-1.37，I = 30%）和赘生物大小>10mm（RR 1.87，95%CI 1.57-2.21，I = 48%）。艾滋病毒、慢性肝病、C 反应蛋白升高、葡萄球菌感染、赘生物存在以及多发性、活动性或人工机械瓣赘生物也会增加 EE 风险，而链球菌感染则会降低 EE 风险。在将来自结局的肺部 EE 研究从敏感性分析中删除后，大多数发现仍然不变。
鉴于栓塞的严重后果，可能需要对具有这些危险因素的患者进行手术评估。
