Long-term incidence of infective endocarditis according to the type of cardiac implantable electronic device: a nationwide comparison with moderate- and high-risk patient groups
A Alhakak, L Ostergaard, M B A Lafta, M Vinther, B T Philbert, H Bundgaard, L Kober, E L FosbolAbstract
Background
According to ESC guidelines, patients with a cardiac implantable electronic device (CIED) are classified as having a moderate risk of infective endocarditis (IE). This classification guides preventive strategies, irrespective of CIED type. A more detailed understanding of IE risk according to specific CIED types is needed to refine risk stratification and prevention.
Purpose
To examine 10-year IE incidence according to CIED type compared with moderate- and high-risk IE populations.
Methods
Using Danish nationwide registries, patients with CIEDs and reference populations at moderate and high risk of IE (2000–2022) were identified based on ESC guideline definitions. The high-risk group included patients with a left-sided prosthetic valve. The moderate-risk group included patients with congenital heart valve anomalies, hypertrophic cardiomyopathy (HCM), left-sided rheumatic heart disease, or left-sided non-rheumatic degenerative valve disease. Patients with prior IE, CIED, or left-sided prosthetic valve surgery were excluded. The cumulative incidence of first-time IE was estimated within 10 years after index date (i.e., discharge), with death treated as a competing risk.
Results
The study included 84,597 CIED recipients, 127,672 patients in the moderate-risk group, and 24,309 patients in the high-risk group. Among CIED recipients, pacemakers were the most common CIED type (N=63,447), followed by implantable cardioverter-defibrillators (ICDs) (N=13,946), cardiac resynchronization therapy with defibrillator (CRT-D) (N=3,872), and CRT with pacemaker (CRT-P) (N=3,332). Pacemaker recipients were the oldest (median 78.2 years), whereas ICD recipients were the youngest (median 64.5 years). The 10-year cumulative incidence of IE was lowest among pacemaker recipients (1.0% [95% CI 0.9–1.1]) and highest among CRT-D recipients (2.2% [95% CI 1.6–2.8]) (Figure). In cause-specific Cox regression analyses, all CIED types were associated with significantly higher 10-year IE rates than the moderate-risk group, but lower rates than the high-risk group (P<0.001). Compared with the moderate-risk group, CRT-D recipients had the highest associated 10-year IE rate (adjusted HR: 2.2 [95% CI 1.66–2.81]), whereas pacemaker recipients had the lowest associated 10-year IE rate (adjusted HR: 1.21 [95% CI 1.08–1.36]).
Conclusions
In this nationwide study, CRT-D recipients had the highest 10-year IE incidence, whereas pacemaker recipients had the lowest. All CIED types were associated with higher adjusted IE risk than the moderate-risk group but lower risk than the high-risk group. These findings are in line with current ESC risk classification, while identifying CRT-D recipients as the subgroup with the highest long-term IE risk, warranting further research into prophylactic strategies.