Pre-admission and in-hospital embolisms have a different prognostic significance in infective endocarditis

To describe the clinical profile of a large cohort of patients with left-sided IE (LSIE) and embolic events (EE); to explore differences between those who present with an embolism at admission (EEa) and those who develop it during hospitalization (EEh); and to compare patients with and without EEa and patients with and without EEh.

We conducted a retrospective cohort study including 482 patients with a definite diagnosis of LSIE from a multicenter Spanish registry between 2000 and 2024. All patients underwent transoesophageal echocardiography (TEE) within 72 h of admission. EE were classified as present at admission or developed during hospitalization. Clinical, echocardiographic, and microbiological characteristics, along with in-hospital mortality, were analysed. Multivariate logistic regression was used to identify predictors of EE during hospitalization and mortality.

Of the 482 patients, 182 (38 %) experienced EE: 122 (25 %) at admission and 73 (15 %) during hospitalization, with 13 patients having both. EEa were associated with atrial fibrillation (AF), Staphylococcus aureus infection, valvular vegetations, and periannular complications, but not with increased mortality (34 % vs. 27 %; p = 0.130). EEh were linked to Streptococcus gallolyticus infection, constitutional symptoms, persistent infection, and absence of heart failure (HF), and were associated with higher mortality (44 % vs. 27 %; p = 0.003). Vegetation size was not associated with EEh. In multivariate analysis, only EEh independently predicted in-hospital mortality (odds ratio 3.03; 95 % confidence interval, 1.66-5.50; p < 0.001).

Among patients with LSIE, EEh are associated with a worse prognosis than those present at admission. Recognizing their timing may help guide clinical decisions and optimize treatment strategies.