存在和不存在基础心脏病的感染性心内膜炎患者临床特点及预后的比较研究
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摘要
目的:比较有基础心脏病和无基础心脏病感染性心内膜炎(IE)患者的临床特点及预后。方法:回顾性分析2007年1月至2016年12月在浙江大学医学院附属第一医院确诊为IE的402例成人(≥16岁)住院患者的临床资料,比较有基础心脏病和无基础心脏病IE患者的临床特点、影响预后的相关因素。结果:无基础心脏病IE患者占总IE患者的45.5%(183/402);其中,27.3%(50/183)合并慢性疾病,37.1%(68/183)存在易感因素。与有基础心脏病的IE患者相比,无基础心脏病IE患者右心及全心受累比例更低(P=0.001),多瓣膜受累更少见(P<0.001),心力衰竭、心律失常、瓣周脓肿等心脏并发症的发生率更低(P均<0.05),但住院病死率和1年病死率差异无统计学意义(P均> 0.05)。多因素分析显示,年龄≥65岁(OR=14.6,95%CI:1.7～124.0,P=0.014)、长期血液透析(OR=20.0,95%CI:1.4～128.9,P=0.027)和Pitt≥2分(OR=83.9,95%CI:13.9～746.8,P<0.001)是无基础心脏病IE患者住院死亡的独立危险因素。无基础心脏病并发栓塞IE患者的1年生存率明显低于非栓塞患者(81.0%vs 95.9%,P=0.002);手术治疗患者的1年生存率明显高于非手术治疗患者(95.3%vs 84.8%,P<0.001)。结论:无基础心脏病IE并不少见且多有易感因素,出现心脏并发症的比例相对较低,病死率较低,预后较好。年龄≥65岁、长期血液透析和Pitt评分≥2是住院死亡的独立危险因素。合并栓塞事件的患者1年生存率较低;抗生素联合手术治疗可以提高1年生存率。
Objectives: To compare the clinical characteristics and prognosis among infective endocarditis(IE) patients with or without underlying heart disease.Methods: In this retrospective analysis, we analyzed the clinical data of 402 IE patients(over 16 years old) with(n=219)or without(n=183) IE who were hospitalized in the First Affiliated Hospital of Medical College of Zhejiang University from January 2007 to December 2016. The clinical characteristics and prognosis were compared between IE patients with or without underlying heart disease.Results: 50 out of 183(27.3%) IE patients without underlying heart disease had chronic disease and 37.1%(68/183)patients had susceptible factors. Prevalence of right heart and whole heart involvement(P=0.001), multivalve involvement(P<0.001) and cardiac complications such as heart failure, arrhythmia and periarticular abscess(P<0.05) were significantly lower in patients without underlying heart disease than patients with underlying heart disease. There were no significant difference between the two groups in aspect of in-hospital mortality and 1-year mortality(P>0.05). Multiple regression analysis showed that age ≥ 65 years(OR = 14.6, 95% CI: 1.7-124.0, P=0.014), long-term hemodialysis(OR=20.0, 95% CI:1.4-128.9, P=0.027) and Pitt score≥2 points(OR=83.9, 95%CI: 13.9-746.8, P<0.001) were independent risk factors for inhospital mortality in patients without underlying heart disease. The 1-year survival rate in patients with IE complicated embolism was significantly lower than that of non-embolized patients(81.0% vs 95.9%, P=0.002). The 1-year survival rate in patients treated with antibiotic combined with surgery was significantly higher than that of antibiotic treatment alone(95.3%vs 84.8%, P<0.001).Conclusions: IE is not rare among patients without underlying heart disease. Most of them have susceptible factors and the proportion of heart complications and mortality rate are low in these patients. Age≥65 years, long-term hemodialysis, and Pitt score≥2 are independent risk factors for in-hospital mortality. The 1-year survival rate of patients with embolizationis low, and antibiotic combined surgical treatment option could improve the 1-year survival in these patients.
Objectives: To compare the clinical characteristics and prognosis among infective endocarditis(IE) patients with or without underlying heart disease.Methods: In this retrospective analysis, we analyzed the clinical data of 402 IE patients(over 16 years old) with(n=219)or without(n=183) IE who were hospitalized in the First Affiliated Hospital of Medical College of Zhejiang University from January 2007 to December 2016. The clinical characteristics and prognosis were compared between IE patients with or without underlying heart disease.Results: 50 out of 183(27.3%) IE patients without underlying heart disease had chronic disease and 37.1%(68/183)patients had susceptible factors. Prevalence of right heart and whole heart involvement(P=0.001), multivalve involvement(P<0.001) and cardiac complications such as heart failure, arrhythmia and periarticular abscess(P<0.05) were significantly lower in patients without underlying heart disease than patients with underlying heart disease. There were no significant difference between the two groups in aspect of in-hospital mortality and 1-year mortality(P>0.05). Multiple regression analysis showed that age ≥ 65 years(OR = 14.6, 95% CI: 1.7-124.0, P=0.014), long-term hemodialysis(OR=20.0, 95% CI:1.4-128.9, P=0.027) and Pitt score≥2 points(OR=83.9, 95%CI: 13.9-746.8, P<0.001) were independent risk factors for inhospital mortality in patients without underlying heart disease. The 1-year survival rate in patients with IE complicated embolism was significantly lower than that of non-embolized patients(81.0% vs 95.9%, P=0.002). The 1-year survival rate in patients treated with antibiotic combined with surgery was significantly higher than that of antibiotic treatment alone(95.3%vs 84.8%, P<0.001).Conclusions: IE is not rare among patients without underlying heart disease. Most of them have susceptible factors and the proportion of heart complications and mortality rate are low in these patients. Age≥65 years, long-term hemodialysis, and Pitt score≥2 are independent risk factors for in-hospital mortality. The 1-year survival rate of patients with embolizationis low, and antibiotic combined surgical treatment option could improve the 1-year survival in these patients.
引文
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[9]胡琳,李渝芬,张智伟,等.无基础心脏病的感染性心内膜炎患者25例临床分析[J].岭南心血管病杂志,2016,22(4):433-436.
[10]郭然,王珂.无基础心脏病和感染诱因的感染性心内膜炎14例临床特点分析[J].中国医师进修杂志,2007,30(34):46-48.
[11]马晶茹,高勇,徐旺达,等.正常瓣膜发生感染性心内膜炎1例[J].中国心血管杂志,2005,10(3):238-239.
[12]Imataka K,Kitahara Y,Naito S,et al.A new model for infective endocarditis of the mitral valve in rabbits[J].Am Heart J,1993,125(1):1353-1357.
[13]Varona JF,Guerra JM.Tricuspid valve endocarditis in a nonaddicted patient without predisposing myocardiopathy[J].Rev Esp Cardiol,2004,57(10):993-996.
[14]娄秀芬,刘正印,杨德彦,等.无基础心脏病感染性心内膜炎30例分析[J].实用心脑肺血管病杂志,2008,16(9):42-43.
[15]Miranda WR,Connolly HM,Desimone DC,et al.Infective endocarditis involving the pulmonary valve[J].Am J Cardiol,2015,116(12):1928-1931.DOI:10.1016/j.amjcard.2015.09.038.
[16]Miranda WR,Connolly HM,Bonnichsen CR,et al.Prosthetic pulmonary valve and pulmonary conduit endocarditis:clinical,microbiological and echocardiographic features in adults[J].Eur Heart J Cardiovasc Imaging,2016,17(8):936-943.DOI:10.1093/ehjci/jew086.
[17]Pettersson GB,Coselli JS,Hussain ST,et al.2016 the American Association for Thoracic Surgery(AATS)consensus guidelines:surgical treatment of infective endocarditis:executive summary[J].J Thorac Cardiovasc Surg,2017,153(6):1241-1288.DOI:10.1016/j.jtcvs.2016.09.093.
[18]Oliver L,Lavoute C,Giorgi R,et al.Infective endocarditis in octogenarians[J].Heart,2017,103(20):1602-1609.DOI:10.1136/heartjnl-2016-310853.
[19]Taradin GG,Vatutin NT,Prendergast BD,et al.Infective endocarditis in the elderly:the current view of the problem[J].Ter Arkh,2016,88(11):128-137.DOI:10.17116/terarkh20168811128-137.
[20]Sundermann SH,Dademasch A,Seifert B,et al.Frailty is a predictor of short-and mid-term mortality after elective cardiac surgery independently of age[J].Interact Cardiovasc Thorac Surg,2014,18(5):580-585.DOI:10.1093/icvts/ivu006.
[21]Njuguna B,Gardner A,Karwa R,et al.Infective endocarditis in Low-and middle-income countries[J].Cardiol Clin,2017,35(1):153-163.DOI:10.1016/j.ccl.2016.08.011.
[22]陈星伟,刘亚欣,于欢,等.阜外医院感染性心内膜炎300例临床特征分析[J].中国循环杂志,2018,33(11):1102-1107.DOI:10.3969/j.issn.1000-3614.2018.11.014.
[2]Linhartova K,Benes J,Gregor P.2015 ESC guidelines for the management of infective endocarditis.Summary document prepared by the Czech Society of Cardiology[J].Cor Et Vasa,2016,58(1):E107-E128.DOI:10.1016/j.crvasa.2015.12.004.
[3]Toyoda N,Chikwe J,Itagaki S,et al.Trends in infective endocarditis in California and New York State,1998-2013[J].JAMA,2017,317(16):1652-1660.DOI:10.1001/jama.2017.4287.
[4]Ambrosioni J,Hernandez-Meneses M,Tellez A,et al.The changing epidemiology of infective endocarditis in the twenty-first century[J].Curr Infect Dis Rep,2017,19(5):21-30.DOI:10.1007/s11908-017-0574-9.
[5]桂龙升,张利斌,毛新,等.静脉药瘾感染性心内膜炎29例诊治体会[J].中国循环杂志,2012,27(5):369-371.DOI:10.3969/j.issn.1000-3614.2012.05.014.
[6]Cahill TJ,Prendergast BD.Infective endocarditis[J].Lancet,2016,387(10021):882-893.DOI:10.1016/s0140-6736(15)00067-7.
[7]Fernandes E,Olive C,Inamo J,et al.Infective endocarditis in French West Indies:a 13-year observational study[J].Am J Trop Med Hyg,2017,97(1):77-83.DOI:10.4269/ajtmh.16-0514.
[8]Van Den Brink F,Hasenaar J,Winia V,et al.Prognostic factors in infective endocarditis in general hospitals in the Netherlands[J].Neth Heart J,2016,24(12):717-721.DOI:10.1007/s12471-016-0846-2.
[9]胡琳,李渝芬,张智伟,等.无基础心脏病的感染性心内膜炎患者25例临床分析[J].岭南心血管病杂志,2016,22(4):433-436.
[10]郭然,王珂.无基础心脏病和感染诱因的感染性心内膜炎14例临床特点分析[J].中国医师进修杂志,2007,30(34):46-48.
[11]马晶茹,高勇,徐旺达,等.正常瓣膜发生感染性心内膜炎1例[J].中国心血管杂志,2005,10(3):238-239.
[12]Imataka K,Kitahara Y,Naito S,et al.A new model for infective endocarditis of the mitral valve in rabbits[J].Am Heart J,1993,125(1):1353-1357.
[13]Varona JF,Guerra JM.Tricuspid valve endocarditis in a nonaddicted patient without predisposing myocardiopathy[J].Rev Esp Cardiol,2004,57(10):993-996.
[14]娄秀芬,刘正印,杨德彦,等.无基础心脏病感染性心内膜炎30例分析[J].实用心脑肺血管病杂志,2008,16(9):42-43.
[15]Miranda WR,Connolly HM,Desimone DC,et al.Infective endocarditis involving the pulmonary valve[J].Am J Cardiol,2015,116(12):1928-1931.DOI:10.1016/j.amjcard.2015.09.038.
[16]Miranda WR,Connolly HM,Bonnichsen CR,et al.Prosthetic pulmonary valve and pulmonary conduit endocarditis:clinical,microbiological and echocardiographic features in adults[J].Eur Heart J Cardiovasc Imaging,2016,17(8):936-943.DOI:10.1093/ehjci/jew086.
[17]Pettersson GB,Coselli JS,Hussain ST,et al.2016 the American Association for Thoracic Surgery(AATS)consensus guidelines:surgical treatment of infective endocarditis:executive summary[J].J Thorac Cardiovasc Surg,2017,153(6):1241-1288.DOI:10.1016/j.jtcvs.2016.09.093.
[18]Oliver L,Lavoute C,Giorgi R,et al.Infective endocarditis in octogenarians[J].Heart,2017,103(20):1602-1609.DOI:10.1136/heartjnl-2016-310853.
[19]Taradin GG,Vatutin NT,Prendergast BD,et al.Infective endocarditis in the elderly:the current view of the problem[J].Ter Arkh,2016,88(11):128-137.DOI:10.17116/terarkh20168811128-137.
[20]Sundermann SH,Dademasch A,Seifert B,et al.Frailty is a predictor of short-and mid-term mortality after elective cardiac surgery independently of age[J].Interact Cardiovasc Thorac Surg,2014,18(5):580-585.DOI:10.1093/icvts/ivu006.
[21]Njuguna B,Gardner A,Karwa R,et al.Infective endocarditis in Low-and middle-income countries[J].Cardiol Clin,2017,35(1):153-163.DOI:10.1016/j.ccl.2016.08.011.
[22]陈星伟,刘亚欣,于欢,等.阜外医院感染性心内膜炎300例临床特征分析[J].中国循环杂志,2018,33(11):1102-1107.DOI:10.3969/j.issn.1000-3614.2018.11.014.