Hospitalizations for Stroke Associated With Infective Endocarditis and Opioid Use: National Trends

A recent study published in Circulation Stroke conducted by Omran et al. reported that the US hospitalization rates for stroke associated with infective endocarditis and opioid use were stable for roughly about 2 decades but then sharply increased in 2008, coinciding with the emergence of the opioid epidemic.

In recent times, there has been an increase in opioid-related deaths in the United States. Intravenous opioid use may lead to infective endocarditis (IE) which may subsequently result in stroke. Data on recent trends in this neurological complication of opioid use is scant. In this study, the investigators hypothesized that increasing opioid abuse has led to a higher incidence of stroke associated with infective endocarditis and opioid use. Omran and his colleagues used the 1993 to 2015 releases of the National Inpatient Sample and validated International Classification of Diseases, Ninth Revision, Clinical Modification codes (ICD-9-CM) to identify hospitalizations with the combination of opioid abuse, infective endocarditis, and stroke (defined as ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage). The investigators used survey weights provided by the National Inpatient Sample to calculate nationally representative estimates and population estimates from the United States. The annual hospitalization rates per 10 million person-years were calculated using census data. In addition to this, trends were assessed with the use of joinpoint regression. The results of the study showed that from 1993 through 2015, there were 5283 hospitalizations with stroke associated with infective endocarditis and opioid use. Across this entire duration, it was noted that the rate of such hospitalizations increased from 2.4 (95% CI, 0.5–4.3) to 18.8 (95% CI, 14.4–23.3) per 10 million US residents. Finally, joinpoint regression detected 2 segments: no significant change in the hospitalization rate was apparent from 1993 to 2008 (annual percentage change, 1.9%; 95% CI, −2.2% to 6.1%), and then rates significantly increased from 2008 to 2015 (annual percentage change, 20.3%; 95% CI, 10.5%–30.9%), most drastically in non- Hispanic white patients in the Northeastern and Southern United States.

In conclusion, the investigators of the study determined that the opioid epidemic in the United States led to a rising number of hospitalizations, cardiovascular complications, and deaths. In 2016, approximately 11.8 million people reported misusing opioids, including a rough estimate of about 1 million people who used heroin. Emergency department visits and hospitalizations related to opioid abuse had been increasing by 5% annually while opioid-related deaths had quintupled in the past 20 years. Omran et al. also noted that there had been a demographic shift, with the largest increase in opioid abuse occurring in women, younger patients, and non-Hispanic whites. Similarly, the pattern of drugs associated with opioid-related deaths has changed, with the number of deaths from heroin, usually injected intravenously, having tripled since 2010!

In 2008, during the worsening of the opioid epidemic, there was a sharp increase in US hospitalization rates from stroke associated with infective endocarditis. Moreover, the northeastern and southern United States experienced the greatest increases in the rate of hospitalization for stroke associated with IE and opioid use over this time period. Highlighting the findings of his study, primary investigator Setareh Salehi Omran stated, “These findings add to the urgency of addressing the underlying opioid epidemic in the United States and suggest a need for improved awareness of the cerebrovascular complications of opioid abuse. In a large, nationally representative sample, we found that US hospitalization rates for stroke associated with infective endocarditis and opioid use were stable for roughly 2 decades before rising sharply in 2008, which coincides with known trends in opioid abuse in the United States. We found that non-Hispanic whites in the Northeastern and Southern United States experienced the greatest increases in stroke hospitalization rates over our study period. Additionally, while stroke hospitalizations increased across ages and sexes, the greatest increases occurred in women and those <45 years old over the past decade.”