Bias: does it account for low surgical rates in women with infective endocarditis?

In recent years, there has been increasing evidence of sex-related disparities in diagnostic investigations, medical therapies, referrals for invasive care as well as health services, and outcomes across a range of cardiovascular conditions.1–3 While several factors including sex-specific differences in age, physiological differences and comorbidities might contribute to these differences, adjusting for these variables often leaves sex as an independent predictor of treatments as well as outcomes; women are underdiagnosed, under referred and undertreated, and suffer worse outcomes across several cardiovascular conditions. Relatively little is known about sex differences in clinical profile, surgical referrals and outcomes in infective endocarditis (IE). IE appears to occur in men more commonly than women, with sex differences in the microbial profile, aetiology and comorbidities of patients with IE.4–6 Some of these differences may translate to differences in outcomes, but evidence in this regard has varied. The decision around both the receipt of surgical intervention and its timing in IE is complex and depends on many factors (figure 1), which include the size of the vegetation, the nature of the infective organism, the presence of paravalvular infection particularly with evidence of heart block or annular/periaortic abscesses, embolic phenomena, presentation with valve dysfunction resulting in symptoms or signs of heart failure, patient age, comorbidities and overall surgical risk, but importantly should not include sex per se.7 It is recommended by international guidelines that decisions around both the indication and timing …