Impact of diagnostic and treatment delays on mortality in infective endocarditis: results from a large patient population study

Abstract Background In the management of Infective Endocarditis (IE), guidelines emphasize the importance of avoiding delays, especially when emergency or urgent surgical interventions are required. However, in clinical practice, these timing recommendations are often not followed, resulting in dangerous therapeutic delays. Purpose The causes of diagnostic and treatment delays in IE have not been systematically analyzed. This study aims to quantify and explore the reasons behind such delays. Methods We analyzed a large series of consecutive IE cases to compare the survival outcomes of patients who receive timely treatment according to guideline recommendations (Group 1, "In-Time") versus those who experienced delays (Group 2, "Delayed"). We also examined the reasons for delays in intervention. Results From January 1998 to March 2024, 384 consecutive cases of definite infective endocarditis were diagnosed, yielding an incidence rate of 6.78 per 100,000/year. A 1-year follow-up was completed for all patients. Of the 254 patients (66.1%) who had an indication for cardiac surgery, only 170 underwent the procedure. The remaining 84 patients did not receive surgery, and the reasons were as follows: Prohibitive surgical mortality risk (53.6%) due to critical conditions, including severe septic shock and/or neurological complications; Patient refusal (10 cases); Death while waiting for surgery (29 patients, 34.5%). The study also examined various time intervals: 1) Symptoms to admsission: The longest delay, accounting for 51% of the total delay, occurred between the onset of symptoms and hospital admission. 2) Symptoms to Diagnosis: The time from the first symptoms to echocardiographic diagnosis averaged 29 days in patients without predisposing conditions, versus 36 days in those with a higher risk for IE (p=0.156) 3) Time TTE to TEE: The mean delay between transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) was 4.3 days in patients without high-risk factors and 4.7 days in high-risk patients, with no significant difference. 4) Surgical Delay: The interval from the time of surgical indication to intervention was significantly longer for patients without high-risk factors (61.8 vs 50.7 days; p=0.001). Figure 1. Regarding the major outcomes: 1) In-hospital Mortality: 27.6% of patients died during hospitalization. Figure 2 2) 1-year Mortality: the overall 1-year mortality rate was 29%. Mortality was higher in Group 1 ("In-Time"), with 47% mortality, compared to 11% in Group 2 ("Delayed"). Notably, 29 patients died while waiting for surgery. Conclusions A diagnostic or treatment delay is one of the most important risk factors for mortality in IE. High risk patients and General practitioners should be educated to be aware of the risk of endocarditis and not underestimate suspicious symptoms. In-hospital diagnostic delays due to difficult access to imaging techniques should be avoided as a suspected IE is always an urgent indication.Analysis of dealys In-hospital mortality