Infective Endocarditis Mortality Hardly a Success Story for the U.S.

— Small dent observed over 25 years, but trends worsening in young, male, and non-urban populations

WASHINGTON -- If any recent progress can be claimed regarding infective endocarditis mortality in the U.S., it was at best inconsistent and at worst a mask for more harmful trends, a retrospective study found.

Overall, using CDC WONDER mortality records, investigators found that the national age-adjusted rate of infective endocarditis mortality went from around 4.2 per 100,000 people to 4.1 per 100,000 from 1999 to 2024.

The trend was nonlinear as these deaths moved in several phases: stable or slightly upward in 1999-2005, declining significantly in 2005-2009, stable in 2009-2018, sharply upward in 2018-2021, and sharply downward in 2021-2024, according to Mariapaula Ordonez Giraldo, MD, of AdventHealth Sebring in Florida, reporting at the IDWeekopens in a new tab or window annual meeting.

Moreover, on subgroup analysis, some sociodemographic and geographic groups in fact saw a worsening of these deaths from 1999 to 2024:

• Age-adjusted infective endocarditis mortality declined among adults age ≥65 years (from 26.07 to 23.59 per 100,000 people), while it rose among younger (15-44 years; 0.60 to 0.84 per 100,000) and middle-age adults (45–64 years; 3.06 to 3.30 per 100,000).
• Fewer of these deaths occurred in women (from 3.95 to 3.41 per 100,000), whereas there were increasingly more among men (4.64 to 4.90 per 100,000).
• In non-metropolitan areas, these deaths were going upward (from 4.35 to 4.95 per 100,000), while metropolitan areas showed a decrease (4.23 to 4.02 per 100,000).

"One of the main messages from our study is that national averages may not tell the whole story. Mortality followed a non-linear trajectory over time, and patterns differed across age, sex, and geography. These findings identify important population-level patterns, but further studies using individual-level clinical and risk-factor data are needed to understand the mechanisms driving them," Ordonez Giraldo told MedPage Today.

She took care to caution that attempts to explain these trends would be outside the scope of the present study, given that the dataset lacked individual-level clinical or behavioral information.

She also noted that deaths in the CDC WONDER database were included in the study if infective endocarditis was recorded on the death certificate -- not if infective endocarditis was the underlying cause of death.

However, she did surmise that the "changing pattern among younger adults may occur in the broader context of injection-drug-use-associated infective endocarditisopens in a new tab or window and evolving risk exposures."

Moreover, the COVID-19 pandemic undoubtedly coincided with the sharp uptick in infective endocarditis deaths reported in the present study. Prior work found an initial drop in infective endocarditis diagnoses early on during the pandemic, suggestive of patients avoiding medical careopens in a new tab or window during those years, followed by subsequent observations that patients admitted with infective endocarditis after COVID-19 were more medically complex and had worse outcomesopens in a new tab or window than before.

"Healthcare utilization and delivery changed substantially after 2020," Ordonez Giraldo said.

"Infective endocarditis requires timely recognition and multidisciplinary care. Potential opportunities to reduce mortalityopens in a new tab or window include early diagnosis; coordinated infectious diseases, cardiology, and cardiac surgery expertise when appropriate; and integration of addiction care for patients with substance-use-associated disease," she stressed. "Our geographic findings also highlight the importance of access to specialized care."