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 Table of Contents  
Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 12-16

Pattern and predictors of outcomes for infective endocarditis in North Kuala Lumpur

1 Department of Cardiology, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia
2 Department of Cardiology, Faculty of Medicine, Universiti Teknologi MARA, Selangor; Institute of Pathology, Laboratory and Forensic Medicine I-PPerForM, Universiti Teknologi MARA, Malaysia

Date of Web Publication8-Mar-2017

Correspondence Address:
Dr. Sazzli Kasim
Faculty of Medicine, UiTM, Kampus Sungai Buloh, Jalan Hospital, 47000 Sungai Buloh, Selangor
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2321-449x.201744

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Context: Infective endocarditis (IE) still carries significant mortality and morbidity ever since 1835. Despite improvement in medical technologies, mortality outcome remains unchanged. We sought to analyze the pattern of presentation, treatment, and outcomes predictors for patient presenting to our hospital. This study will explore some of the factors that could be associated with the outcome of a patient diagnosed with IE for a better guidance in management.
Subjects and Methods: This is a retrospective dual center cohort study from North Kuala Lumpur from January 2012 to December 2013. Fifty patients with definite IE based on modified Duke's criteria were recruited into the study. Clinical presentation, risk factors, biochemical markers, echocardiography, and outcome were obtained through chart review, clinic data, and telephone call. Simple logistic regression was utilized for inferential statistic.
Results: A total of 50 patients, 37 (74%) males and 13 (26%) females were included in the study. The mean age was 42 ± 16.4. Most patients (80.39%) were diagnosed within the 1st week of admission. Staphylococcus aureus was the most common pathogen (38%) and the mitral valve was predominantly affected (68%). Complication was common and in-hospital mortality remains high (28%). Nearly 20% of the patients who had surgical intervention survived and discharged alive. Presence of complications predicts poor outcome (odds ratio [OR]: 5.5 P = 0.02), whereas surgical intervention predicts good outcome (OR: 1.56 P = 0.027).
Conclusions: Mortality remains relatively high in patient with IE. Those who presented with complications are at 5.5-fold risk of mortality. Surgical intervention showed an association with good outcome within this cohort.

Keywords: Endocarditis, infective endocarditis, valvular heart disease

How to cite this article:
Ibrahim KS, Ismail JR, Yusof Y, Yuhana Y, Ahmad Saman MS, Khir N R, Lim CW, Ibrahim O Z, Rahman EA, Chua N, Zainal Abidin HA, Mohd Arshad MK, Kasim S. Pattern and predictors of outcomes for infective endocarditis in North Kuala Lumpur. Heart India 2017;5:12-6

How to cite this URL:
Ibrahim KS, Ismail JR, Yusof Y, Yuhana Y, Ahmad Saman MS, Khir N R, Lim CW, Ibrahim O Z, Rahman EA, Chua N, Zainal Abidin HA, Mohd Arshad MK, Kasim S. Pattern and predictors of outcomes for infective endocarditis in North Kuala Lumpur. Heart India [serial online] 2017 [cited 2018 May 26];5:12-6. Available from: http://www.heartindia.net/text.asp?2017/5/1/12/201744

  Introduction Top

Infective endocarditis (IE) continues to be a major challenge in modern medicine. Despite major advances in both diagnostic and therapeutic procedures, mortality rates have not changed in the past 25 years.[1],[2],[3],[4],[5],[6] The current in-hospital mortality for patient with IE is 15%–23%, with a 1-year mortality approaching 40%.[1],[3],[5],[7],[8]

In developed countries, IE mainly affects aging population with comorbidities. It presents acutely with high rates of Staphylococcus aureus infection and complications such as cardiogenic shock and embolization.[9],[10],[11] Global registries tend to under report IE patterns from developing nations and identify patterns pertinent to Western medicine.[9] One study from a low-middle income region highlighted a high incidence of IE in patients with rheumatic heart disease.[12] Published data from upper middle-income countries are lacking. We hereby sought to describe patterns of IE and predictors of outcome from this region.

The main objective was to describe the characteristic of patients admitted with IE from North Kuala Lumpur, an urbanized region of Malaysia.

  Subjects and Methods Top

Study population

All patients admitted to Sungai Buloh Hospital and Selayang Hospital between January 2012 and December 2013 with definite IE according to modified Duke's criteria were included in the study. These two general hospitals have a catchment area of 1.5 million and serve the north of Kuala Lumpur. Patients were identified from the electronic medical record system using keyword search of endocarditis, IE, and subacute bacterial endocarditis. This study received ethical approval from the Institutional Ethics Committee.

Data collection

The electronic database for patients with clinical diagnosis of IE was retrospectively reviewed. For each patient, the following information was collected: demographics, comorbidities such as diabetes, end-stage renal failure on dialysis, intravenous drug use (IVDU), and HIV infection, clinical presentation, laboratory findings, treatment modality, complications, and outcomes. The definition for IE complications such as severe valve dysfunction, heart failure, septic shock, and embolization are based on contemporary guideline.[13] The type of echocardiography (transthoracic, transesophageal, or both), valve involved, and presence of vegetation were recorded. The valve involved was determined by the presence of vegetation, abscess, and fistula on echocardiogram. Outcomes measures were in-hospital mortality and discharge alive. Good outcome is defined as patient discharged alive and poor outcome is defined as in-hospital mortality.

Statistical analysis

For descriptive analysis, measurement of mean and standard deviation (SD) was calculated for the numerical data. Frequency and proportion were employed for categorical data. As for inferential statistics, simple logistic regression was utilized in calculating crude odd ratio and the 95% confidence intervals for the predictors with significance value was set at 0.05 (P < 0.05). SPSS for Windows, version 19.0 (IBM Corp., Armonk, NY, USA) was utilized for the analysis. The operational definition of the dependent variable was outcome after completion of medical therapy which were alive (fully resolved or referred for surgical intervention) and death.

  Results Top

A total of 196,364 hospital admission electronic medical records were screened during the study period. Fifty-four medical records fulfilled the search criteria. Four patients did not fulfill the Duke's criteria for definite IE and were excluded from the study.

In the study group (n = 50), the mean age was 41.5 ± 16.4 SD. The majority were males (74%) and diagnosed with IE within the 1st week of admission to hospital.

The most common predisposing factors were IVDU which occurred in 13 patients, diabetes mellitus in 9, and valvular heart disease in 6 patients. Three patients had colonoscopy done before symptoms of IE. Seventeen out of fifty patients did not have known predisposing factors [Table 1].
Table 1: Patients' characteristic and clinical examination findings

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Forty-nine out of fifty patients (98%) presented with fever. New murmurs and raised inflammatory markers were clues leading to a diagnosis of IE. None of our patients had immunological manifestation of IE such as Osler's node and Janeway lesions [Table 2].
Table 2: Clinical findings in patient with infective endocarditis

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All patients had at least one set of blood culture taken during hospitalization. Staphylococcus is the predominant microorganism followed by Streptococcus. Microbiological breakdown is given in [Figure 1].
Figure 1: Causative microorganisms in infective endocarditis. CONS = Coagulase-negative Staphylococcus

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Echocardiography was performed in all patients, and vegetation was identified in all. Nearly 16% of participants had concurrent transthoracic and transesophageal echocardiogram. The mitral valve is most commonly affected (n = 24, 48%). Most cases had single valve lesions (80%), with multiple valve involvement affecting ten patients [Table 3].
Table 3: Vegetation site

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Complications of endocarditis in our study include severe valvular regurgitation (32%), shock (18%), systemic embolization other than stroke (12%), and stroke (10%) [Table 4]. Of the fifty patients, 10 (20%) were referred for surgical management. All of the surgically treated endocarditis patients were alive on discharge. In patients who were treated with antibiotics only, 25 (50%) were discharged alive. One patient took self-discharge and was lost to follow-up.
Table 4: Complication of endocarditis

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Mortality occurred in 28% of our cohort. Eleven patients died due to complication of IE and three patients died due to hospital-acquired pneumonia. Those cases were not referred for surgical intervention as they were deemed non-suitable. Embolization was the most common complication that was associated with 3.5-fold increase in mortality. Similarly, patient developing shock had a 4-fold increase in mortality.

Presence of complication predicted poor outcome (OR: 5.5. P =0.02). Septic or cardiogenic shock has been shown as strongest predictor for poor outcome, followed by embolization (non-stroke) and stroke [Table 4]. For predictor of good outcome, surgical intervention showed a significant association (OR: 1.56, P = 0.027). Other parameters such as gender, age, clinical presentations, type of organisms, and site of vegetation have no association as predictor of outcome.

  Discussion Top

We describe the first series of patients with endocarditis from the North Kuala Lumpur region. Most of our patients were young with a third having no risk factors. Overall mortality is high at 29%.

Our findings revealed that most patients within this cohort presented without classical signs of IE. This is consistent with the findings from the International Collaboration on Endocarditis-prospective study (ICE-PCS) in 2009 which showed similar changes in the characteristics of IE.[9] Our study differs from published literature from the period between 1960 and 1980 which documented immunological manifestation in almost 50% of patients with endocarditis.[2],[14],[15],[16]

IVDU is a significant risk factor to contract IE (26%).[17] Similar findings were observed from the East Coast of Malaysia and Hong Kong.[18],[19] This is in contrast to data from ICE-PCS where the majority of IE from developing countries had degenerative valvular heart disease.[9] Another study from India highlighted the younger age of affected patients along with the presence of rheumatic heart disease as risk of contracting IE.[20] Among the IVDU group, S. aureus was most common, and right-sided valves were mainly affected consistent with previous published study.[17] Urbanization may be a factor, contributing to a higher rise of alcohol and drug abuse.[21]

Culture-negative IE made up 32% of our cohort. This is unusually high in comparison to contemporary data which showed a rate of culture-negative IE between 14% and 19%.[22],[23] This trend was last seen in the 1980s.[24] The use of antibiotics before hospital admission might contribute to this occurrence.

Systemic embolization is the most common complication, occurring in up to 50% of patients with endocarditis.[2],[25],[26],[27],[28] It is associated with high mortality.[25],[29],[30] In our study, nine patients had embolization with mortality occurring in 5 (56%).

The indications for surgical intervention in our study include embolic phenomenon, severe acute mitral regurgitation, large vegetation of more than 1 cm, fungal IE, and endocarditis in the presence of congenital heart defect. The survival rate seen in postsurgical patients is consistent with prior studies, emphasizing the need for early intervention when indicated, especially when medical intervention has failed.[31],[32],[33]

  Conclusions Top

In contrast to developed nations, an upper middle-income country such as Malaysia is seeing a high burden of endocarditis arising from IVDU patients. This pattern is different from a low middle-income country where rheumatic heart disease predominates.

Our study highlights the need for further research into disease patterns among different health care and population environment to gain maximum yield from resource allocation.


We acknowledge the potential population bias our study would carry as we sourced patients from tertiary hospitals without cardiac services. We may be missing out on the less complicated IE patterns that are seen in the smaller district and rural regions. We acknowledge the need to have a prospective study to validate our findings.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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