Analysis of sex differences in the clinical presentation, management and prognosis of infective endocarditis in Spain

Correspondence to Dr Laura Varela Barca, Cardiac surgery, Hospital Universitario Fundacion Jimenez Diaz, 28034 Madrid, Spain; [email protected]

Introduction

Sex-dependent differences in cardiovascular diseases have been previously recognised.¹ There are several differences in clinical characteristics, treatment strategies, comorbidities and outcomes among men and women.²

In the case of infective endocarditis (IE), these differences are also evident, and sex differences have been previously described.³ Although women suffer from IE less frequently than men, they tend to have more severe manifestations and are more prone to have worse outcomes.^3–5 The location of IE was described to be different between sexes, probably because of the differences in predisposing lesions.⁶ In addition, in cases of sepsis⁷ and shock, sex differences have been demonstrated. Surgical outcomes have also been described to be worse in women after cardiac surgery,^{8 9} and female sex is generally considered an independent mortality risk factor after heart surgery.¹⁰

Nevertheless, there is no clear understanding of the impact of sex on the prognosis of medically treated IE, surgical referral or surgical outcomes. Contradictory observations have been previously published, as some studies found a clear impact of sex on surgical outcome,^{11 12} whereas these sex differences were described as not being related to prognosis in others.^13–15 Consequently, there is no clear understanding of the impact of these sex differences.

We conducted an analysis of the sex differences in a large, national-level multicentric cohort of patients affected of IE (‘Spanish Collaboration on Endocarditis’ or GAMES cohort).

The objectives of the present study were as follows: (1) describe the sex-related differences in the presentation of IE; (2) analyse the modality of treatment and surgical referral in men and women and (3) analyse the prognosis of IE between sexes through analysis of the differences in in-hospital mortality.

Materials and methods

Patients

This was an observational, multicentric, prospective study based on a nationwide registry (GAMES registry) that included all consecutive patients with a diagnosis of definite IE according to the modified Duke criteria.^{16 17} A total of 3451 patients were included between January 2008 and December 2018. Patients with IE related to cardiac device infection without valvular involvement were excluded from the study because of the marked differences in the...