Endocarditis in Brazil: what do two decades of mortality reveal?ABSTRACT
Introduction: Infective endocarditis is a serious condition caused by infection of the endocardium, prosthetic valves or cardiac devices. Its incidence has increased worldwide, currently being 1.5-11.6 cases per 100,000 people and in-hospital mortality rates ranging from 17,5-30%.
Objective: To analyze the epidemiological profile, temporal trends, and spatial distribution of mortality from acute and subacute endocarditis in Brazil between 2001 and 2021, identifying patterns and priority areas for intervention.
Method: Epidemiological study with temporal and spatial analysis, using death data from the Mortality Information System (SIM/DATASUS) and population data from the IBGE to calculate crude and standardized rates.
Results: Between 2001 and 2021, 15,448 deaths from acute and subacute endocarditis were recorded in Brazil, with an approximate increase of 3% in mortality over the period. The highest frequency was observed in individuals aged 60-69 years (21,22%), males (61,20%), white (61,67%), with low schooling (4-7 years of schooling) and married marital status. Most deaths occurred in a hospital environment (97.24%). The spatial analysis showed a higher concentration of mortality in the South and Southeast regions, with emphasis on specific municipalities. There was significant positive spatial autocorrelation.
Conclusion: Mortality from endocarditis showed a slight increase in the period studied, concentrated in vulnerable population groups and in specific regions of the country, reinforcing the need for regional strategies for prevention, early diagnosis, and adequate management of cardiovascular risk factors.
KEYWORDS:
Endocarditis; Spatio-temporal analysis; Mortality records
RESUMO
Introdução: A endocardite infecciosa é condição grave causada por infecção do endocárdio, de válvulas protéticas ou de dispositivos cardíacos. Sua incidência tem aumentado em todo o mundo, sendo atualmente de 1,5-11,6 casos por 100.000 pessoas e taxas de mortalidade hospitalar que variam entre 17,5-30%.
Objetivo: Analisar o perfil epidemiológico, as tendências temporais e a distribuição espacial da mortalidade por endocardite aguda e subaguda no Brasil entre 2001 e 2021, identificando padrões e áreas prioritárias para intervenção.
Método: Estudo epidemiológico com análise temporal e espacial, utilizando dados de óbitos do Sistema de Informações sobre Mortalidade (SIM/DATASUS) e dados populacionais do IBGE para cálculo de taxas brutas e padronizadas.
Resultados: Entre 2001 e 2021, foram registrados 15.448 óbitos por endocardite aguda e subaguda no Brasil, com aumento aproximado de 3% na mortalidade ao longo do período. Observou-se maior frequência em indivíduos de 60-69 anos (21,22%), do sexo masculino (61,20%), de raça branca (61,67%), com baixa escolaridade (4-7 anos de estudo) e estado civil casado. A maioria dos óbitos ocorreu em ambiente hospitalar (97,24%). A análise espacial evidenciou maior concentração de mortalidade nas regiões Sul e Sudeste, com destaque para municípios específicos. Houve autocorrelação espacial positiva significativa.
Conclusão: A mortalidade por endocardite apresentou leve crescimento no período estudado, concentrando-se em grupos populacionais vulneráveis e em regiões específicas do país, reforçando a necessidade de estratégias regionais de prevenção, diagnóstico precoce e manejo adequado dos fatores de risco cardiovasculares.
PALAVRAS-CHAVE:
Endocardite; Análise espaço-temporal; Registros de mortalidade
INTRODUCTION
Infective endocarditis (IE) is a serious condition caused by infection of the endocardium, prosthetic valves, or cardiac devices. Its incidence has increased worldwide, currently being 1,5-11,6 cases per 100,000 people and hospital mortality rates ranging from 17.5% to 30%.1 O Global Burden of Disease Study showed its growth, with 1.09 million cases registered in 2019 and an age-adjusted rate of 13,8 per 100,000 people, compared to 9,9 in 1990. In 2019, the highest incidence rates occurred in tropical and southern Latin America. Mortality rates also increased, ranging from 0,7 to 0,9 per 100,000, being higher in southern Latin America, Oceania and high-income North America.2
It is important to note that the epidemiological profile of IE has changed, contributing to high morbidity and mortality. The incidence has grown among patients with risk factors, such as advanced age, comorbidities, prosthetic valves, and cardiac devices. In addition, an increase in cases of IE of nosocomial origin has been reported in the literature.1 Moreover, other epidemiological characteristics such as predisposing factors and causative microorganisms are different between geographic regions. Predisposing factors include rheumatic heart disease, which is very present in developing countries such as Brazil, as well as degenerative heart disease or intravenous drug use, which are more common in developed countries. However, in Latin America, synthesized data on characteristics and trends of the IE are scarce.2
The etiology of IE shows an increase in cases of Staphylococcus aureus and a significant reduction in viridanos group streptococci in North America, while in Latin America no changes were observed over the decades. Globally, S. aureus is predominant, with variation of secondary microorganisms.2
A study conducted with data from Latin America showed that the main cardiovascular risk factors were a history of heart valve disease (24.3%), followed by the presence of prosthetic heart valve (23.4%). The most frequent comorbidities were hypertension (38.1%) and diabetes mellitus (15.8%). Previous surgical or endoscopic procedures, catheter or indwelling device, and previous procedures were associated with IE in 21.9%, 20.9%, and 5.6%, respectively.2
The main clinical manifestations are fever, dyspnea, Osler’s nodules, petechiae, malaise, presence of heart murmur, with the possibility of developing complications, the main ones being heart failure, embolic events and septic shock.2
In a systematic review analyzing blood culture data in 41 studies, including 4032 blood cultures, 23.9% had negative blood cultures.2 Several factors influence this occurring, such as inadequate microbiological techniques and previous use of empirical antibiotic therapy before the diagnostic analysis.3
The main surgical indications are left ventricular ejection dysfunction due to heart failure and/or valve dysfunctions, failure in clinical treatment, and echocardiographic vegetation greater than 10 mm. Emergency surgery may also be indicated due to severe cardiocirculatory shock.3 Techniques such as Ozaki aortic valve repair and transaortic mitral valve repair with autologous pericardium stand out.
IE has important complications on patients due to the high proportion of future complications such as development of heart failure (36.4%) or embolic events (27.1%), leading to the need for surgery. Surgery was reported in 42% of cases in a systematic review looking at EI in Latin America, lower than the Euro-Endo registry, which reported 51.2% and a Japanese national study, 61%. Regarding mortality associated with the surgical treatment of endocarditis, studies analyzing in-hospital mortality found an overall in-hospital mortality of 25.1% (37 studies with n of 1027/4095) and overall mortality, including late and unspecified periods, of 26.6%.2
METHOD
This is an epidemiological study of secondary data analysis in health with a focus on temporospatial analysis. Data on cases of death due to acute and subacute endocarditis were obtained from the Mortality Information System (SIM) of the Department of Informatics of the Unified Health System (DATASUS) of the Ministry of Health (MS), via Tabnet, through the place of death and place of occurrence. The population data used as denominator for the purpose of calculating mortality rates came from DATASUS.
For the analysis of the mortality trend due to acute and subacute endocarditis in Brazil, the period from 2001 to 2021 was selected, in order to better understand the outcome in this historical series. For the study population, individuals were selected, according to data available from the Department of Informatics of the Unified Health System (DATASUS) for adults who were registered with deaths from acute and subacute endocarditis. The following variables were considered for the analysis: sex, age group, color/race, marital status, education, deaths by residence, year of death, place of death, and place of occurrence.
For the underlying cause of these deaths, ICD I33 of the International Classification of Diseases (ICD-10) was adopted. Information on the epidemiological profile and frequency of deaths from acute and subacute endocarditis were compiled using the Microsoft Excel for Microsoft 365 MSO software. Thus, the nominal variables were analyzed by means of the absolute frequency and percentage of occurrence in the study population. Annual mortality was calculated using the total number of deaths in the state as the numerator and the population of the state in that year as the denominator, taking 100,000 inhabitants as a reference for this coefficient. While the mortality of each municipality was calculated based on standardization by the indirect method, using the average number of cases in the period, divided by the average population between 2001 and 2021, multiplied by 100, 000 inhabitants.
Initially, the temporal trend of mortality due to acute and subacute endocarditis was analyzed (Figure 1). Thus, the annual percent change (APC) of the studied trend was evaluated, with a 95% confidence interval (95%CI) and statistical significance p < 0.05. The analysis of the temporal pattern was performed using the Joinpoint Regression Program 5.0.2 2023 software. Next, the spatial distribution of mortality from acute and subacute endocarditis in Brazil was analyzed. Initially, the mean mortality of them in Brazilian municipalities was created (Figure 1). As there is a probability of identifying a heterogeneous pattern between municipalities, the municipal values were smoothed by the local empirical Bayesian method. This method weights the value of the municipal tax in relation to the municipalities that border it through a spatial proximity matrix. The spatial analyses were carried out in the GeoDa 1.22.0.4 2023 program, as well as the creation of the thematic maps.
To identify spatial clusters, the Global and Local Moran’s Index was used, which measures the correlation between first-order neighbors and was used to test the hypothesis of spatial dependence. The method identifies spatial autocorrelation and can vary between -1 and +1, in which values close to zero indicate the absence of spatial dependence, considering p < 0.05 to be significant. If the hypothesis of dependence is accepted, the Local Index of Spatial Association (LISA) was used to observe the presence of spatial aggregates, given p < 0.05. The results of the analyses described above were demonstrated by Moran Map and LISA Map (Figure 4). The Moran Map graphically demonstrates the degree of similarity between neighbors, being represented by four quadrants: 1) high-high (upper right quadrant) which corresponds to municipalities that have high mortality rates and are close to municipalities that also have high mortality rates; 2) low-low (lower left quadrant) that correspond to municipalities that have low mortality rates and are close to municipalities that also have low mortality rates; 3) high-low (lower right quadrant), correspond to municipalities that have high mortality rates and are close to municipalities that have low mortality rates; 4) low-high (upper left quadrant) that correspond to municipalities that have low mortality rates and are close to municipalities that have high mortality rates.
The data used to compose the survey are available on the internet for free consultation. Thus, there is no possibility of causing physical or moral damage from the perspective of the individual and the collectivity. Therefore, the present study did not need to be approved by the Ethics Committee.
RESULTS
After a meticulous analysis of the profile of Brazilian victims of acute and subacute endocarditis, a significant prevalence was identified among those aged between 60 and 69 years, totaling 21.22% of the cases. However, it is notable that the incidence of this fatal event is practically comparable in close age groups, with 17.54% of deaths occurring between 50-59 years of age, and 19.37% among 70-79 years of age. In addition, there was a marked predominance of males, representing 61.20% of the cases. At the same time, most of the victims belonged to the white ethnicity (61.67%) and had the marital status of married (45.25%).
Regarding the educational level, it was observed that most deaths occurred among individuals with 4-7 years of complete schooling, comprising 20.46% of the cases, followed by 18,25% among those with 8-11 years of complete schooling. It is crucial to highlight that most cases of mortality due to acute and subacute IE occurred in a hospital environment, representing 97.24% of the total.
From 2001 to 2021, 15,488 deaths from acute and subacute IE were recorded in Brazil. The average mortality in this period was 0.37/100,000 inhabitants, with the lowest mortality recorded in 2002 (0.26/100,000 inhabitants) and the highest in 2019 (0.47/100,000 thousand inhabitants). The analysis of the temporal pattern of mortality in the period from 2001 to 2021 showed a significant mean increase of 3% per year in the mortality rate per 100,000 inhabitants (p < 0,05, Figure 1). Pearson’s correlation coefficient was 0,9674 with p < 0.05, indicating that there is a significant and proportional linear correlation, with an increase in the mortality rate over the years.
Temporal pattern of mortality from acute and subacute endocarditis in Brazil between 2001-2021
Through spatial analysis, Figure 2 shows the spatial dispersion of mortality due to acute and subacute endocarditis in Brazil, with a focus of incidence in the South and Southeast regions, Torre de Pedra, SP (6.15/100,000 inhabitants), Serranos, MG (4.70/100,000 inhabitants), Protásio Alves, RS (4.69/100,000 inhabitants), Ourizona, PR (4.14/100,000 inhabitants) and Porteirão, GO (4.11/100,000 inhabitants) were the five municipalities that presented the highest mortality rate due to acute endocarditis and subacute between 2001-2021.
With the smoothing of the crude rates by the local empirical Bayesian method (Figure 3), it is possible to observe a more apparent spatial pattern, with aggregation of municipalities with higher mortality rates in the South, Southeast and Midwest regions. Spatial autocorrelation was identified by the Global Moran Index (I = 0.779; p = 0.01), demonstrating evidence of positive autocorrelation.
The application of the Local Moran’s Index made it possible to identify spatial clusters of both high and low equal values (Figure 4). The high-high pattern was identified mainly in the South, Southeast and Midwest regions, which indicates similarity of the municipalities in these regions for high mortality values from the disease analyzed, while the low-low pattern was identified mainly in the North and Northeast regions, which indicates similarity between the municipalities in these regions for low mortality values from the pathology analyzed.
Mortality rate smoothed by the local empirical Bayesian method for acute and subacute endocarditis in Brazil between 2001-2021
Spatial clusters of mortality from acute and subacute endocarditis in Brazil between 2001-2021
DISCUSSION
The temporal and spatial analysis of mortality from IE in Brazil between 2001 and 2021 reveals a complex mosaic of determinants and challenges of public health. IE is a rare condition associated with endocardial infection, but associated with high morbidity and mortality.1,2,4-6 The incidence of IE is estimated at 3-10 cases per 100,000 people, but an increase in its incidence has been observed in the last decade (13.8/100,000), especially in tropical countries and Latin America.4,5,7 Associated with the case, an increase in mortality was also observed in the period 1990-2019, ranging from 0.7 to 0.9 per 100,000, with Latin America, Oceania, and North America being the regions with the highest mortality rates in 2019. 5.7
The increase in mortality due to IE found in this study is in line with recent studies and may be related to recent changes in the epidemiological profile. In a period of about 30 years, mortality due to endocarditis increased by about 2.3 times, both in men and women, which reflects population growth and the maintenance of high morbidity and mortality.1,5 Although there has been an improvement in the population’s standard of living, with greater availability of antibiotics to combat rheumatic fever, other risk factors stand out, such as advanced age, comorbidities, cardiac devices, and prosthetic valves.1,5 In addition, there is an increase in mortality due to nosocomial endocarditis, which varies between 17-30%, a fact also observed in the present study, in which about 97% of deaths occur in the hospital environment.1 The vast mortality observed in the hospital environment is explained by several additional risk factors, such as: etiology caused by Staphylococcus aureus, negative blood cultures, valve abscess, heart failure secondary to IE, and septic shock.7 Thus, considering the great impact of endocarditis and its diagnostic complexity, the optimization of its evaluation and treatment is essential to avoid undesirable clinical outcomes, and specialized and multidisciplinary protocols can be used according to the severity of the condition.
In general, corroborated by the world literature, the incidence of IE is higher in men, which may explain the marked predominance of males as victims of the disease (61.2%) observed in this study.2 As a result, it is reported by Urina-Jassir et,al 5 that there was a predominance of males in 68.5% of the cases, a situation confirmed by Yang et,al,5 who observed an incidence of 16.2/100,000 in men, compared to 11.6/100,000 in women in 2019, This can be explained by the presence of associated risk factors, Thus, a large percentage of cases are related to preexisting heart disease, mainly valve disease, prosthetic valves, rheumatic heart disease, and congenital heart diseases, Although the epidemiological panorama is different between countries with unequal socioeconomic levels, rheumatic heart disease remains an important cause of mortality in developing countries. It is noteworthy that in developed countries, the presence of intracardiac implantable devices, as well as the use of intravenous medications, diabetes and cancer, have replaced rheumatic heart disease as the main risk factors.2.5
In addition, another factor that draws attention is the prevalence of mortality due to acute and subacute IE in elderly individuals. Recent studies have proven an increase in the burden of diseases, especially in individuals over 60 years of age,5 which clarifies the high death rates evidenced between 60 and 69 years of age in this study. This significant increase in old age is multifactorial and refers both to immunosenescence, observed in this population, and to the consequences of their comorbidities.5,8,9 With the increase in life expectancy, the population lives longer with multiple comorbidities, degenerative valve diseases, as well as being more susceptible to interventional treatments, such as cardiac device implants (pacemakers) and hemodialysis, which are known risk factors for the disease in question.5 In addition, the high mortality in this population segment is explained by their nutritional deficiencies, as well as their reduced functional capacity, which are recognized as independent predictors of mortality. Thus, it is clear that the disproportion in the mortality of elderly patients is related to multiple comorbidities, long hospitalization and medical devices, requiring a multidisciplinary approach based on increasing the response capacity of the health system due to the variation in epidemiological profiles and considering that the global population aged 80 years and over tends to triple between 2017-2050. Nevertheless, associating early discharge with oral therapies is beneficial because it has been shown to be non-inferior to intravenous therapy exclusively for gram-positive bacteria in IE.8
In addition, the incidence of deaths from acute and subacute endocarditis reflects a dispersed pattern, with varied and heterogeneous prevalence in the Brazilian regions, with higher mortality rates in the South, Southeast, and Midwest regions, proven by the smoothing of crude rates by the local empirical Bayesian method and by the analysis of spatial clusters. Due to the lack of national studies on this specific point, such a spatial pattern of unequal distribution of mortality due to IE may be indicative, in part, of variations in living conditions and demographic profiles, in the distribution of health resources, as well as socioeconomic inequalities. This finding may represent the existing difference in access to resources in Brazil, evidencing how health disparities may be rooted in socioeconomic differences, shaping the risk of multifactorial diseases and the responsiveness of the health system due to the monopolization of resources. This fact raises questions about equity in access to health, since the low prevalence of deaths in other regions of the country may be caused by the complete absence of diagnosis, mainly due to precarious access to diagnostic structures and, consequently, underreporting of cases. Therefore, in view of the great diagnostic challenge and increase in incidence and mortality rates, it is clear the need for intervention programs that prioritize, from health promotion to the optimization of access to quality medical care services, and should therefore be multidisciplinary and intersectoral in order to ensure equity in public health.
The association observed between lower schooling and higher mortality from IE consistently reflects the role of social determinants of health in the clinical outcomes of the disease. Large-scale population studies have shown that low educational attainment is independently associated with increased mortality from cardiovascular and infectious causes, even after adjusting for age, sex, and other risk factors, evidencing schooling as a structural determinant of health.9,10 Individuals with lower education have greater exposure to risk factors, lower health literacy, and greater difficulty in recognizing early symptoms and seeking timely medical care, which favors late diagnosis and worse prognosis.11 In addition, low education is often associated with unfavorable socioeconomic conditions, a higher prevalence of chronic comorbidities, and lower adherence to treatment, factors known to be related to increased cardiovascular and infectious mortality.12 The literature also indicates that populations with lower educational levels are more vulnerable to severe infections and unfavorable clinical outcomes, especially in the elderly and those with chronic diseases. Thus, the findings of this study reinforce that the higher mortality from IE among individuals with low education is not limited to isolated biological factors, but reflects persistent social inequalities, highlighting the need for public policies aimed at strengthening health literacy, expanding access to specialized services, and reducing educational inequities as a strategy to mitigate mortality associated with the disease.9-11
The secondary data used in this research are a limiting factor, which can generate biases, such as underreporting, lack of information, and inconsistencies in filling in the causes of death. Associated with this, there is a limitation in the analysis of information on population estimates through the indirect method, as the last census dates from 2010. The results found for the general population may not be repeated at the individual level, due to the effects of data aggregation, characteristic of the ecological fallacy. It is noteworthy that the mortality analysis was based only on the underlying cause of death and not on multiple causes. Thus, there may be underestimation of deaths from acute and subacute endocarditis,
Thus, the temporospatial analysis allowed the identification of the Brazilian regions with high mortality from endocarditis and the differences between the mortality rates for acute and subacute endocarditis between the municipalities of the state. In this way, the need for strategies that are in line with the reality and particularities of these places is exposed. This research serves as a scientific subsidy for the organization and planning of actions aimed at improving health care in the most vulnerable places, especially Primary Health Care (PHC), aiming to ensure access and care for this population and consequently promote health and prevent endocarditis aggravations.
CONCLUSION
Mortality from acute and subacute endocarditis in Brazil showed a slight increase between 2001 and 2021, with heterogeneous spatial distribution and greater concentration in the South and Southeast regions. Deaths predominantly affected elderly individuals, males and those with a lower level of education, evidencing the influence of clinical and social determinants on disease outcomes. The presence of significant spatial autocorrelation reinforces the need for integrated regional strategies, aimed at strengthening early diagnosis, qualifying hospital care, and reducing inequalities in access to health services, with the aim of mitigating mortality associated with infective endocarditis in the country.
References
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Central Message
Infective endocarditis is a serious condition caused by infection of the endocardium, prosthetic valves, or cardiac devices. Its incidence has increased worldwide. In 2019, the highest incidences occurred in tropical and southern Latin America. Mortality also increased, being higher in southern Latin America, Oceania and high-income North America. Thus, analyzing the epidemiological profile, temporal trends, and spatial distribution of mortality from acute and subacute endocarditis in Brazil is important to identify patterns and priority areas for intervention
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Perspective
As mortality due to endocarditis showed a slight increase in the studied period, concentrating in vulnerable population groups and in specific regions of the country, the need for regional strategies for prevention, early diagnosis, and adequate management of cardiovascular risk factors is reinforced. With this, better results can be presented in terms of their frequency and mortality.
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How to cite this article
de Souza FR, Dias LM, Okimura V, Bauer RB, Dias LM, Nadolny L, Possiedi RD, Kubrusy LF. Endocardite no Brasil: o que duas décadas de mortalidade revelam? BioSCIENCE. 2026;84:e00008. https://doi.org/10.55684/2026.84.pt.e00008
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Funding:
None
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Data availability:
Data are available from the corresponding author upon reasonable request.
Edited by
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Associate Editor:
Ramiro Colleoni Neto https://orcid.org/0000-0002-5429-3692
Data are available from the corresponding author upon reasonable request.
Source: The authors (2024)
Source: The authors (2024)
Source: The authors (2024)
Source: The authors (2024)