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Risk Classification for Mortality

Rodrigo Hasbun, MD; Holenarasipur R. Vikram, MD; Lydia A. Barakat, MD; Joan Buenconsejo, MPH; Vincent J. Quagliarello, MD

JAMA. 2003;289:1933-1940.

Context  Complicated left-sided native valve endocarditis causes significant morbidity and mortality in adults. Lack of valid data regarding estimation of prognosis makes management of this condition difficult.

Objective  To derive and externally validate a prognostic classification system for adults with complicated left-sided native valve endocarditis.

Design, Setting, and Patients  Retrospective observational cohort study conducted from January 1990 to January 2000 at 7 Connecticut hospitals among 513 patients older than 16 years who experienced complicated left-sided native valve endocarditis and who were divided into derivation (n = 259) and validation (n = 254) cohorts.

Main Outcome Measure  All-cause mortality at 6 months after baseline.

Results  In the derivation and validation cohorts, the 6-month mortality rates were 25% and 26%, respectively. Five baseline features were independently associated with 6-month mortality (comorbidity [P = .03], abnormal mental status [P = .02], moderate to severe congestive heart failure [P = .01], bacterial etiology other than viridans streptococci [P<.001 except Staphylococcus aureus, P = .004], and medical therapy without valve surgery [P = .002]) and were used to create a prognostic classification system. In the derivation cohort, patients were classified into 4 groups with increasing risk for 6-month mortality: 5%, 15%, 31%, and 59% (P<.001). In the validation cohort, a similar risk among the 4 groups was observed: 7%, 19%, 32%, and 69% (P<.001).

Conclusions  Adults with complicated left-sided native valve endocarditis can be accurately risk stratified using baseline features into 4 groups of prognostic severity. This prognostic classification system might be useful for facilitating management decisions.

Author Affiliations: Infectious Disease Section, Tulane University School of Medicine, New Orleans, La (Dr Hasbun); Infectious Disease Section, Hospital of St Raphael, New Haven, Conn (Dr Vikram); Infectious Diseases, Griffin Hospital, Derby, Conn (Dr Barakat); Yale University School of Epidemiology and Public Health, New Haven, Conn (Ms Buenconsejo); and Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn (Dr Quagliarello).

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