496 Internacional Journal of Cardiovascular Sciences. 2015;28(6):496-503 ORIGINAL MANUSCRIPT Hospital Evolution of Patients with Infective Endocarditis in Public Hospital in Belém, Pará, Brazil Lucianna Serfaty de Holanda1, Juliana Fonseca de Araújo Daher1, Alberto Freire Sampaio Costa2, Dilma Costa de Oliveira Neves1, Vitor Bruno Teixeira de Holanda3 1Centro Universitário do Estado do Pará – Curso de Graduação em Medicina – Belém, PA – Brazil 2Centro Universitário do Estado do Pará – Hospital de Clínicas Gaspar Vianna – Serviço de Cardiologia – Belém, PA – Brazil 3Hospital Saúde da Mulher – Serviço de Cardiologia – Belém, PA – Brazil Abstract Background: The time course of disease knowledge enables advances in techniques that promote early diagnosis which, consequently, is important for the survival of patients with infective endocarditis (IE). Objective: To describe the hospital evolution of patients with infective endocarditis in a public hospital in Belém, Pará, Brazil. Methods: Observational, descriptive, prospective case series study. The study included a review of the medical records of 18 patients with IE from Hospital de Clínicas Gaspar Vianna (HCGV), who were part of the hospital’s spontaneous demand and who met the inclusion criteria adopted. Social and demographic data and clinical evolution were analyzed. Results: Of the 18 patients studied, there was predominance of males (72.2%), aged between 39-59 years (50.0%), level of education: incomplete primary education (61.1%) and monthly income two to four minimum wages (55.5%). The most prevalent risk factor was the presence of biological valve prosthesis (36.0%), 66.5% of blood cultures were negative, the aortic valve was the most affected (44.4%). Valve dysfunction was the most frequent complication (26.5%), the medical and surgical treatment was the most used (55.5%), criterion for surgery was severe impairment (33.3%). The time to diagnosis was 27.7 days, time to treatment after diagnosis was 2.4 days and the outcome most found was death (50.0%). Conclusion: Half of the patients died with a percentage well above what is found in the literature. Keywords: Endocarditis, bacterial; Endocarditis; Clinical evolution Introduction The main gateways of microorganisms in the bloodstream are oral cavity, skin and upper airways. The initial event in the development of infective During simple procedures, such as dental treatment, endocarditis (IE) is endothelial injury caused by transient bacteremia may occur, during which the deposition of immune complexes ─ such as in rheumatic microorganisms settle on preexisting clots, generating disease ─ or turbulent blood flow ─ as in mitral valve an infected vegetation, which may lead to the destruction reflux ─ giving rise to nonbacterial thrombotic of the involved structure, as well as other surgeries in endocarditis (NBTE)1. general2-6. Corresponding author: Luciana Serfaty de Holanda Av. Alm Barroso, 3775 – Souza - 66613-903 – Belém, PA – Brazil E-mail: [email protected] DOI: 10.5935/2359-4802.20150076 Manuscript received on December 11, 2015; approved on January 15, 2016; revised on February 02, 2016. Int J Cardiovasc Sci. 2015;28(6):496-503 Holanda et al. 497 Original Manuscript Hospital Evolution of Patients with IE Diagnosis of IE is based on the modified Duke criteria The time course of disease knowledge and imaging methods in the recognition of valvular enabled advances in diagnostic techniques, ABBREVIATIONS AND ACRONYMS vegetations which, combined with clinical and especially in echocardiography. In 1,7 bacteriological data, enable a more precise diagnosis . addition, there was a greater possibility • CHF — congestive heart Echocardiography currently stands out as an essential of performing heart surgery, even with failure diagnostic tool, and it identifies complications, provides the infectious process in activity, and • HCGV – Hospital de Clínicas prognostic information and assists in the proper new prophylaxis recommendations for Gaspar Vianna management of patients8,9. Transthoracic antibiotics before intervention procedures15. • IE — infective endocarditis echocardiography (TTE) has a lower cost and greater • IV — intravenous As for treatment, with early surgical availability in hospitals, while transesophageal • NBTE — nonbacterial echocardiography (TEE) results in higher accuracy8,10. repair, another presentation of the thrombotic endocarditis disease appeared, namely prosthesis • TEE — transesophageal The choice of echocardiographic modality must consider endocarditis, which is difficult to echocardiography the clinical pre-test probability of the disease. The diagnose and difficult to establish • TTE — transthoracic 12 echocardiography employment of TTE is considered appropriate when this therapeutic management . probability is between 2-3%, while TEE must be used With the emergence of new increasingly when the probability is between 4-60%8,10,11. effective antibiotics, clinical treatment has enabled the cure of endocarditis with or without associated surgical The evolution of echocardiography, with the possibility treatment12. of transesophageal tests, allowed viewing changes that were not possible with TTE and even less with the first According DATASUS16, mortality from IE in Pará has echocardiography devices. The type of treatment and its been increasing steadily. Within five years (2009 to 2013), time have also changed12. 76 deaths from IE were recorded, with an approximate average of 5 deaths/year, ranging from 10 deaths in New imaging techniques in cardiology, including 2010 to 20 deaths in 2012, without restriction to sex and magnetic resonance imaging and computed tomography age. scans have been used in the evaluation of this disease, with promising results8. The total number of deaths in the state of Pará, in individuals aged 15-80, from 2010-2013, was 92,178; of Advances in laboratory tests allowed faster and more this number, 54 were from IE14. There is no data for the accurate detection of the etiological agents causing the years 2014 and 2015. In Belém, state of Pará, there were 12 problem and more effective mitigation of these agents . 23 deaths from IE, as follows: 5 in 2011, 10 in 2012 and When available for heart surgery or autopsy, pathology 8 in 201316. tests of the vegetation is the gold standard for diagnosing 8 endocarditis and can suggest its etiology . Given the few studies on infective endocarditis in Brazil, especially in the last decade12 and the progressive increase IE presents high morbidity and mortality with mortality of mortality from IE, due to systemic complications, rates of 20-30%, rising up to over 50% in high-risk groups. despite the advances in diagnostic methods and The prognosis correlates with rapid diagnosis and proper treatment, this study aims to analyze the hospital 4,10,13,14 therapy . evolution of patients affected by IE considering the social and demographic profile and the risk factors involved. Complications may occur by destruction of structures at the site of infection, embolic events, metastatic lesions and immune-mediated infections2. Methods The emergence of congestive heart failure (CHF) An observational, descriptive, prospective case series secondary to embolization adversely impacts the study with analysis of medical records of 18 patients with prognosis of the disease. Other complications include infective endocarditis from Hospital Gaspar Vianna in perivalvular and myocardial abscesses2. Belém, PA, Brazil, from January 2010 to April 2015. 498 Holanda et al. Int J Cardiovasc Sci. 2015;28(6):496-503 Hospital Evolution of Patients with IE Original Manuscript This study was approved by the Research Ethics (p<0.0001). There was a predominance of monthly Committee of the institution under nº 1.030.404/ 2015 income between two and four minimum wages in 55.5% according to the CNS Resolution 466/12. Because it is a (n=10) of the cases. retrospective study, Informed Consent Form was not required. Biological valve prosthesis was the most common risk factor (36.0%) followed by hemodialysis (16.0%) and The inclusion criteria were: patients who were part of dental procedures (12.0%) (p=0.0028). the hospital’s spontaneous demand, with infective endocarditis, of both sexes, aged ≥18 and ≤90 or with The most common complications found in patients with reported IE, with positive blood culture tests, IE after diagnosis was valvular impairment (26.5%), echocardiogram and/or histopathology tests conducted followed by congestive heart failure and sepsis, with no in HCGV, as well as those with a diagnosis established significant difference (p=0.598) (Table 1). by the modified Duke criteria17. Patients with incomplete medical records and those who were no longer in the Table 1 hospital files were excluded. Complications experienced by patients after diagnosis of infective endocarditis The following sociodemographic variables were collected from the medical records: age, sex, education, Complications n % average monthly household income and origin. Risk factors: mitral valve prolapse, rheumatic disease, Valvar impairment 9 26.5 * complex congenital heart disease, use of intravenous drugs, septal hypertrophy, previous dental procedure, Congestive heart failure 7 20.6 * hemodialysis, diabetes mellitus, HIV infection, Sepsis 7 20.6 * mechanical valve prosthesis or bioprosthetic valve, type of pathogens (determined through blood test results or Acute renal failure 4 11.8 histopathology test results), affected cardiac valves, medical complications after IE, diagnostic method