Although interest in male-female differences in cardiovascular disease is growing, evidence in infective endocarditis (IE) is limited and contradictory. This prospective study included 791 patients with definite or possible IE discussed by the endocarditis team (2016-2025; 73% male, 27% female). Women more often had mitral-valve IE, men more often aortic-valve IE, more predisposing conditions and more Cutibacterium. Although the indication for surgery did not differ, men were operated on more often (41% vs 29%), and women with a surgical indication were more often treated conservatively (37% vs 23%). Over a median 2.1-year follow-up, women had higher adjusted mortality (HR 1.39); after excluding non-operated patients with an indication, surgery appeared more protective in women than men. The findings point to sex differences in surgical decision-making and a less favourable prognosis in women.
Despite growing interest in male–female differences in cardiovascular disease, evidence in infective endocarditis (IE) is limited and contradictory.
This prospective study included all patients with definite or possible valvular IE discussed by 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, IE type and treatment.
The cohort included 791 patients with definite or possible IE (72.8% males, 27.2% females). Age was not different (male: 67 (IQR 56–75), female: 71 (IQR 55–78) years, p=0.07). Females more often had hypertension (46.0% vs 35.2%, p=0.07) and mitral valve IE (45.6% vs 32.3%, p<0.001). Males had more predisposing conditions (71.5% vs 60.5%, p=0.004) and more aortic valve IE (71.0% vs 62.3%, p=0.02) and Cutibacterium species (5.7% vs 1.4%, p=0.007). There was no difference in indication for surgery. However, males were more often treated surgically (41.1% vs 29.3%, p=0.002), and 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 HR (aHR) 1.39 (95% CI 1.03 to 1.89), p=0.03). Surgery was associated with higher mortality in males (aHR 1.32 (95% CI 0.90 to 1.94) vs aHR 0.62 (95% CI 0.32 to 1.20), p value for interaction=0.03).
Differences were observed in baseline characteristics, IE type and survival. Females had worse overall adjusted survival, suggesting a less favourable overall prognosis. In terms of surgical decision-making, surgery was withheld more often in females despite surgical indication, and after excluding these patients, surgery appeared more protective in females than in males. These findings may reflect sex differences in surgical selection.
