What is the correct way to write the cause of death in a case of infective endocarditis according to the Indian consensus?

How to Write Cause of Death in Infective Endocarditis

When documenting cause of death in infective endocarditis cases, write the immediate cause of death (such as heart failure, septic shock, or embolic stroke) on the first line, with "infective endocarditis" listed as the underlying cause on subsequent lines, following the standard medical certificate of cause of death format used in India.

Understanding the Chain of Events Leading to Death

The documentation should reflect the pathophysiological sequence that led to death. In IE, mortality results from specific complications rather than the infection itself:

Most Common Fatal Complications

• Congestive heart failure is the leading cause of death in IE patients and the most common serious complication, occurring when severe valvular regurgitation or obstruction develops 1, 2
• Septic shock represents a critical complication with extremely high mortality, with odds ratio of 20.26 for in-hospital death 3
• Embolic events cause death in 22-50% of cases, with 65% involving the central nervous system, particularly in the middle cerebral artery distribution 1
• Acute renal failure occurs in 6-30% of patients and independently increases risk of in-hospital death 1

Organism-Specific Mortality Patterns

• Staphylococcus aureus infection carries significantly higher mortality (OR 6.47) and should be specifically noted when present 1, 3
• Fungal endocarditis is associated with particularly poor prognosis and represents a main predictor of death 1
• Negative blood cultures paradoxically increase mortality risk (OR 9.14), likely reflecting diagnostic delays or unusual organisms 3

Proper Documentation Format

Line-by-Line Structure

Part I (Direct sequence leading to death):

• Line (a) - Immediate cause: Write the terminal event (e.g., "Cardiogenic shock," "Acute heart failure," "Massive cerebral infarction," "Septic shock")
• Line (b) - Due to: Write the cardiac complication (e.g., "Severe aortic regurgitation," "Periannular abscess with fistula," "Septic embolism")
• Line (c) - Due to: Write "Infective endocarditis" with specific valve involvement (e.g., "Infective endocarditis - mitral valve")
• Line (d) - Due to: Write the causative organism if identified (e.g., "Staphylococcus aureus bacteremia")

Critical Details to Include

• Valve involvement: Specify which valve(s) were affected, as aortic IE carries 40-93% mortality with heart failure versus 17-66% for mitral IE 2
• Prosthetic versus native valve: Prosthetic valve endocarditis (PVE) has different mortality patterns and should be clearly documented 1
• Healthcare-associated status: Note if the infection was healthcare-associated, as this affects epidemiology and outcomes 1

Common Pitfalls to Avoid

• Do not list only "infective endocarditis" as the sole cause - this lacks the specificity needed for accurate mortality statistics 1
• Do not omit the causative organism when known, particularly for high-mortality pathogens like S. aureus or fungi 3, 4
• Do not fail to document periannular extension (abscess, false aneurysm, fistula) when present, as this predicts higher mortality and more frequent need for surgery 1
• Do not overlook valve obstruction documented on echocardiography, which carries OR 8.57 for mortality 3

Special Circumstances Requiring Documentation

Surgical Status

• Emergency/salvage surgery status accounts for the highest mortality rates in registry data and should be noted if surgery was performed 1
• Patients with SOFA scores >15 on day of surgery have extremely poor outcomes 1
• Conversely, cardiac surgery as treatment was protective (OR 0.14) and should be documented when performed 3

ICU-Related Deaths

• Mortality in critically ill IE patients ranges from 29-84%, significantly higher than general IE population 1
• Document if death occurred in ICU setting with multiorgan failure 1

Right-Sided Endocarditis

• Tricuspid valve IE has lower mortality (approximately 7%) compared to left-sided disease 1
• When present in IV drug users, document this context as it affects epidemiology 1, 5

Part II: Other Significant Conditions

List contributory factors that influenced death but were not part of the direct causal sequence:

• Diabetes mellitus (independent predictor of death) 1
• Chronic kidney disease requiring hemodialysis 1
• HIV infection or immunosuppression 1
• Previous valve disease or prosthetic valve 3

This structured approach ensures accurate mortality reporting while capturing the complexity of IE-related deaths for epidemiological purposes and quality improvement initiatives 1, 3.