Key result
CRT-D implantation linked to ~2-fold higher 10-year infective endocarditis risk versus moderate-risk controls.
Why the study?
Comparative data on infective endocarditis incidence across different cardiac implantable electronic device types and risk groups are limited.
Does the long-term risk of infective endocarditis vary by CIED type, and how does it compare to ESC-defined moderate- and high-risk patient groups?
Cohort (n=235,642)
Yes
Does the long-term risk of infective endocarditis vary by CIED type, and how does it compare to ESC-defined moderate- and high-risk patient groups?
Hazard Ratio: 2.03 (95% CI 1.56–2.66)
Absolute Event Rate: 2.2% vs 0.78%
All CIED types carry a higher long-term risk of infective endocarditis than ESC-defined moderate-risk patients but a significantly lower risk than high-risk patients, supporting current guidelines while highlighting that CRT-D recipients face the highest risk among device cohorts.
CIEDs confer intermediate long-term IE risk; supports ESC moderate-risk grouping while extending subtype gradients for prospective study.
AIMS: According to the European Society of Cardiology (ESC) guidelines, patients with a cardiac implantable electronic device (CIED) are considered at moderate risk of infective endocarditis (IE), irrespective of CIED type. However, comparative data across CIED types and IE risk groups are limited. We examined IE rates according to CIED type compared with moderate- and high-risk groups. METHODS AND RESULTS: Danish nationwide registries were used to identify patients with first-time CIED implantation and reference populations at moderate and high risk of IE (2000-2022), based on the ESC guidelines. The high-risk group included patients with a left-sided prosthetic valve. Patients with prior IE or left-sided prosthetic valve were excluded from the CIED group. The primary outcome was incident IE within 10 years. The study included 84 171 CIED recipients, 127 966 moderate-risk patients, and 23 505 high-risk patients. Pacemakers were the most common CIED type (74.9%), followed by implantable cardioverter-defibrillator (16.6%), cardiac resynchronization therapy device with defibrillator (CRT-D) (4.6%), and cardiac resynchronization therapy device without defibrillator (3.9%). Pacemaker recipients were the oldest (median 78.2 years) and most frail. The 10-year cumulative incidence of IE was lowest in pacemaker recipients (1.0% [95% confidence interval (CI): 0.9-1.1]) and highest in CRT-D recipients (2.2% [95% CI: 1.7-2.9]). In adjusted analyses, all CIED types were associated with higher IE rates than the moderate-risk group but lower than the high-risk group. CONCLUSION: In this nationwide cohort, IE risk differed across CIED types, highest in CRT-D and lowest in pacemaker recipients. All CIED types were associated with higher risk than moderate-risk patients but lower risk than high-risk patients, supporting the ESC classification. Cardiac resynchronization therapy device with defibrillator recipients may warrant further evaluation of preventive strategies.
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Alhakak et al. (2026) conducted a cohort in Infective endocarditis (n=235,642). Cardiac implantable electronic device (CIED) implantation vs. ESC-defined moderate- and high-risk patient groups was evaluated on Incident infective endocarditis within 10 years (HR 2.03, 95% CI 1.56-2.66). The 10-year incidence of infective endocarditis ranged from 1.0% for pacemakers to 2.2% for CRT-D, all demonstrating higher adjusted risk than the moderate-risk reference group (HR 2.03 for CRT-D) but lower than the high-risk group.
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