Academic Editor: Takatoshi Kasai
The prognostic value of the sequential organ failure assessment (SOFA) score for
critically ill elderly patients with acute infective endocarditis (IE) remains
unknown. From January 2015 to December 2019,
111 elderly (
The epidemiology of infective endocarditis (IE) is changing with a growing proportion of patients who are elderly [1]. The incidence of IE in elderly patients is 4.6 times higher than in the general population, with delayed diagnosis [2, 3]. Medical or surgical treatment for IE in elderly patients remains controversial because of associated high incidence of morbidity and mortality [4]. Accordingly, early identification of patients with an elevated risk of death from IE is essential to improve outcomes in elderly patients. The sequential organ failure assessment (SOFA) score has been confirmed as an effective prognostic tool in the management of sepsis, as well as in IE patients [5, 6, 7]. However, limited data is available on the prognostic value of SOFA in patients with IE who are elderly.
We conducted the first multicenter prospective observational study that evaluated the prognostic value of the SOFA score for in-hospital and long-term mortality of patients aged 65 years and older who were treated for acute IE.
A multicenter prospective observational trial involving acute IE in elderly
patients (
The study was conducted in accordance with the Declaration of Helsinki. The protocol was approved by the Ethics Committee of Shenzhen People’s Hospital (approval number: SZLY0122). All participants provided informed consent prior to participation in the study.
Transthoracic echocardiography and SOFA score were assessed within 24 hours of admission. Transesophageal echocardiography was performed if necessary. Serum samples were collected and analyzed immediately upon admission [C-reactive protein (CRP), 0–5 mg/L; erythrocyte sedimentation rate (ESR), 20 mm/h]. Follow-up data were acquired by telephone at 1 month, 3 months, 6 months and 12 months after discharge from hospitalization.
The primary study endpoint was in-hospital mortality. Secondary endpoint measures included other predictors of in-hospital mortality and all cause death during follow-up.
Statistical analysis was performed by SPSS 22.0 (Chicago, IL, USA). Data were
reported as mean
One hundred and eleven elderly patients with acute IE were included in this
study (29 females, mean age 71.86
Characteristics | Low SOFA | High SOFA | p-value | |
(n = 71) | (n = 40) | |||
Age (years) | 68 (66, 75.75) | 71.5 (67, 77) | 0.029 | |
Females, n (%) | 18 (25.35) | 11 (27.50) | 0.781 | |
AIE, n (%) | 14 (19.72) | 10 (25.00) | - | |
SIE, n (%) | 57 (80.28) | 30 (75.00) | 0.481 | |
Hypertension, n (%) | 18 (25.35) | 14 (35.00) | 0.389 | |
Diabetes mellitus, n (%) | 6 (8.45) | 8 (20.00) | 0.144 | |
Affected valve | ||||
Aortic valve, n (%) | 38 (53.52) | 18 (45.00) | 0.325 | |
Mitral valve, n (%) | 38 (53.52) | 22 (55.00) | 0.900 | |
Tricuspid valve, n (%) | 8 (11.27) | 4 (10.00) | 0.951 | |
8 (11.27) | 9 (22.50) | 0.745 | ||
Congenital heart disease, n (%) | 5 (7.04) | 5 (12.50) | 0.492 | |
Neurological failure (GCS |
6 (8.45) | 10 (25.00) | 0.028 | |
Paravalvular abscess, n (%) | 4 (5.63) | 6 (15.00) | 0.168 | |
Embolic complications, n (%) | 11 (15.49) | 14 (35.00) | 0.040 | |
Stroke, n (%) | 10 (14.08) | 10 (25.00) | 0.207 | |
Heart failure, n (%) | 40 (56.34) | 29 (72.50) | 0.106 | |
NYHA III–IV, n (%) | 18 (25.35) | 22 (55.00) | 0.029 | |
LVEF (%) | 62.90 |
62.29 |
0.717 | |
Temperature, |
38.8 |
38.95 |
0.627 | |
CRP, mg/L | 24.67 |
37.89 |
0.006 | |
SOFA score (interquartile range) | 3.9 (3, 5) | 7.5 (6, 9) | 0.001 | |
ESR, mm/h | 39.06 |
39.50 |
0.917 | |
Pathogen, n (%) | ||||
Staphylococcus aureus | 10 (14.08) | 7 (17.5) | 0.416 | |
Streptococcus spp | 20 (28.17) | 12 (30.00) | 0.738 | |
Healthcare-associated infection | 2 (2.82) | 1 (2.50) | 0.730 | |
Vegetation size |
24 (33.80) | 22 (55.00) | 0.045 | |
Surgery treatment, n (%) | 64 (90.14) | 27 (67.50) | 0.029 | |
In-hospital death | 5 (7.04) | 12 (30.00) | 0.002 | |
Long-term mortality | 7 (9.86) | 11 (27.50) | 0.003 | |
AIE, acute infective endocarditis; SIE, subacute infective endocarditis; NYHA, New York Heart Association; LVEF, left ventricular ejection fraction; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; SOFA, sequential organ failure assessment; GCS, Glasgow Coma Score. #Affected value more than or 2 valves. |
In-hospital mortality, the primary endpoint, was 30% in the
high SOFA score group and 7.04% in the low SOFA score group (p =
0.002). ROC analysis indicated that a SOFA score of
The ROC curves for SOFA in predicting in-hospital mortality in elderly IE patients.
Univariate analysis identified age (odds ratio (OR) = 3.05, p = 0.039),
diabetes mellitus (OR = 3.94, p = 0.032), multiple-valves (OR = 2.10,
p = 0.040), neurological failure (GCS
Univariate (A) and multivariate analyses (B) of factors associated with in-hospital mortality.
Among the 94 patients surviving hospitalization, 1 patient (1.1%) was lost to
follow-up and 18 patients (19.35%) died within the follow-up time of 12–36
months. Long-term mortality, a secondary endpoint, was 27.50% in the high SOFA
score group and 9.86% in the low SOFA score group (p = 0.003).
Kaplan-Meier analysis demonstrated a lower cumulative survival in patients with
SOFA 6–9 and SOFA
Kaplan-Meier analysis (A), Cox regression analysis (B) and Cox proportional-hazards model (C) of SOFA score for survival over 3 years of follow-up.
This study aims to evaluate the utility of SOFA for predicting mortality in critically ill elderly patients with acute IE. The major findings are: (i) a strong predictive value of high SOFA for in-hospital mortality; (ii) high SOFA was associated with long-term mortality; (iii) additionally, age, diabetes mellitus and surgical treatment were independent predictors of clinical outcomes.
With an increase in life expectancy, elderly people susceptible to infectious diseases are more common than ever for physicians. In particular, acute IE in elderly patients is a severe and challenging disease for cardiologists, with high in-hospital mortality rates ranging from 24.9% to 45.3% [9, 10]. Early identification of prognostic factors may offer the opportunity to improve the clinical outcomes of these patients. The SOFA score assesses respiration, coagulation, liver and renal function, cardiovascular health and the central nervous system, using fraction of inspiration O2, platelet count, serum bilirubin and creatinine, blood pressure/pressor use, and the Glasgow coma score, reflecting the severity of organ failure and predicting underlying comorbidities [11, 12]. A SOFA score of 2 or more has been recommended as a criterion for sepsis and has been confirmed as a significant predictor of ICU mortality [7]. Therefore, it is reasonable to expect that obtaining a SOFA score on admission could predict the severity and prognosis of acute IE.
In our study, SOFA
Advanced age (OR, 2.31) has been associated with poor prognosis in acute IE. Our
results were in accordance with studies by Netzer [18] and Selton-Suty [19], who
found that mortality was higher in elderly patients (
Our data also showed that high SOFA (SOFA
We should acknowledge the limitations of the present study. First, this is a
prospective observational trial involving a small population. Thus, there might
be a bias in data selection and analysis. Secondly, younger IE patients (age
SOFA is a straightforward prognostic tool to use for critically ill elderly
patients with acute IE. A SOFA score
YWL, MSW, SHD, FL and HYQ designed, collected, analyzed and wrote this manuscript. BHL, SYG, FL, HDL, JY and DQY assisted in the conduct of study. BHL, SYG, HDL, JY, DQY and HYQ performed the research. YWL, MSW and SHD was the principal investigator.
The study was conducted in accordance with the Declaration of Helsinki. The protocol was approved by the Ethics Committee of Shenzhen People’s Hospital (approval number: SZLY0122). All participants provided informed consent prior to participation in the study.
We would like to express my gratitude to all those who helped me during the writing of this manuscript. Thanks to all the peer reviewers for their opinions and suggestions.
The study was supported by Shenzhen Key Medical Discipline Construction Fund (No. SZXK003) and Sanming Project of Medicine in Shenzhen (No. SZSM201412012).
The authors declare no conflict of interest.