Sex differences in the diagnosis, management, and outcomes of patients with infective endocarditis

Background Despite growing interest in male-female differences in cardiovascular disease, evidence in infective endocarditis (IE) is limited and contradictory. Purpose The purpose of this study was to investigate male-female differences in management and outcomes of patients discussed in our endocarditis team. Methods This prospective study included all patients with (suspected) valvular IE discussed in the endocarditis team from 2016 to 2025. Baseline characteristics, diagnostics, treatment, and outcomes were compared between sexes. A Cox model was conducted to assess survival adjusted for baseline characteristics, type of IE and type of treatment. Results The total cohort included 939 patients, of which 70.8% were male and 29.2% female. Age at presentation was not different between sexes (male: 67 [interquartile range (IQR) 56-75] years, female: 70 [IQR 55-78] years, p=0.16). Females more often had hypertension (43.4% vs. 34.0%, p=0.01) and chronic obstructive pulmonary disease (9.9% vs. 5.9%, p=0.03). Males had more predisposing cardiac conditions (70.7% vs. 59.5%, p<0.001), including prior valve surgery (46.9% vs. 38.3%, p=0.02) and device implantation (12.6% vs. 7.3%, p=0.02). Males more often had aortic valve IE (71.0% vs. 62.3%, p=0.02), whereas females more often had mitral valve IE (45.6% vs. 32.3%, p<0.001). Also, Cutibacterium species were more often found to be the causative pathogen in males (5.7% vs. 1.4%, p=0.01). Although there was no difference in indication for surgery between sexes, males more often underwent surgery (41.1% vs. 29.3%, p=0.002), while females with an indication for surgery were more often treated conservatively(22.5% vs. 37.0%, p=0.006). After a median follow-up of 2.1 [IQR 0.4-4.4] years, females had higher mortality (adjusted hazard ratio(aHR) 1.39 (95% confidence interval (CI) 1.03-1.89), p=0.03, figure 1 and 2). Additionally, we found that surgery was associated with higher mortality in males (aHR 1.32 (95%CI 0.90-1.94) vs. aHR 0.62 (95%CI 0.32-1.20), p-value for interaction=0.03, figure 2). Conclusion Differences were observed in baseline characteristics, IE type, treatment and survival. There were no differences in indication for surgery between sexes, however, females with an indication for surgery were less often operated on. Overall, mortality was higher in females, but notably, mortality post-surgery was higher in males. This warrants attention for sex differences in surgical decision-making.Figure 1Figure 2