Nondental Invasive Procedures and Risk of Infective Endocarditis: Time for a Revisit: A Science Advisory From the American Heart Association.

There have been no published prospective randomized clinical trials that have: (1) established an association between invasive dental and nondental invasive procedures and risk of infective endocarditis; or (2) defined the efficacy and safety of antibiotic prophylaxis administered in the setting of invasive procedures in the prevention of infective endocarditis in high-risk patients. Moreover, previous observational studies that examined the association of nondental invasive procedures with the risk of infective endocarditis have been limited by inadequate sample size. They have typically focused on a few potential at-risk surgical and nonsurgical invasive procedures. However, recent investigations from Sweden and England that used nationwide databases and demonstrated an association between nondental invasive procedures, and the subsequent development of infective endocarditis (in particular, in high-risk patients with infective endocarditis) prompted the development of the current science advisory.

Endocarditis in Adult Congenital Heart Disease Patients: Prevention, Recognition, and Management.

PURPOSE OF REVIEW: Present an updated overview of the prevention, diagnosis, and management of infective endocarditis in adult patients with congenital heart disease. RECENT FINDINGS: Care for patients with infective endocarditis is changing in the areas of specialized teams, diagnostics, and prevention. Endocarditis teams should be involved in the care of ACHD patients. The 2023 Duke Criteria for Infective Endocarditis and the 2023 European Society of Cardiology Guidelines have updated the criteria for diagnosis including new major criteria such as CT and positron emission computed tomography with 18F-fluorodeoxyglucose (FDG) scans. Immunological, PCR, and nucleic acid-based tests are now acceptable means to isolate infective organisms. Clindamycin is no longer recommended for antibiotic prophylaxis due to resistance and side effect profile. Special considerations for antibiotic prophylaxis and management must be made for specific congenital heart diseases in adulthood and pregnant ACHD patients. Infective endocarditis (IE), a potentially devastating clinical entity, is a feared threat to the health of adults with congenital heart disease (ACHD). IE needs a systematic approach for its prevention, early diagnosis and management with a multidisciplinary IE team's involvement. There have been changes in the diagnostics and management of IE, which is reflected in updated diagnostic criteria. Timely blood cultures and imaging continue to be the mainstay of diagnosis, however the timing of blood cultures, microbiological testing, and types of diagnostic imaging such as the positron emission computed tomography with 18F-fluorodeoxyglucose (FDG) scan are new. Bicuspid aortic valves, ventricular septal defects, transcatheter pulmonary valve replacements, and tetralogy of Fallot are diagnoses at higher risk for IE in the ACHD population. The following article will focus on the preventive strategies, in addition to novel diagnostic and therapeutic approaches of IE in ACHD patients.

Infective Endocarditis: Etiology, Epidemiology and Current Recommendations for the Dental Practitioner.

Infective endocarditis (IE) remains one of the most serious diseases with a high morbidity and mortality rate. Although the condition is more common in the medical field in a hospital setting, dentists must have a thorough understanding of the overall pathogenesis, epidemiology, risk factors and signs and symptoms that may be present in their patient population. In 2021, the American Heart Association (AHA) updated its guidelines on IE, emphasizing the specific criteria that put a patient at risk of acquiring IE, specific dental procedures that can increase the risk of IE by inducing bacteremia and an antibiotic prophylaxis regimen to act as a preventive measure if needed. This literature review gives the dental practitioner a general overview of the AHA guidelines as well as information on prevention in their at-risk patients and the need to emphasize a well-structured, consistent daily oral hygiene routine.

Assessment of endocarditis prophylaxis knowledge and attitudes among healthcare practitioners in Tehran and Hamadan.

BACKGROUND: Having knowledge of the dental procedures that necessitate endocarditis prophylaxis is of high importance. Therefore, the aim of the present study was to determine the knowledge level and attitudes of general medical and dental practitioners, dental specialists, and cardiologists in Tehran and Hamadan about endocarditis. METHODS: This cross-sectional study was carried out on 420 general medical and dental practitioners, dental specialists, and cardiologists in Tehran and Hamadan provinces in 2015. The questionnaire used in this research consisted of three parts as follows: part one: information on cardiac diseases; part two: dental procedures requiring endocarditis prophylaxis; part three: antibiotic diet in endocarditis prophylaxis. Independent t-test, one-way ANOVA, and chi-square tests were conducted to analyze the data. All the analyses were performed in SPSS version 16. RESULTS: The results showed that 86.7 had a relatively favorable and 10.5% of subjects had a favorable level of knowledge about endocarditis. Also, 58.6% of subjects had a poor attitude toward endocarditis prophylaxis. There was a significant relationship between knowledge and attitude, age, gender, and work experience (P < 0.001). There was a significant relationship between knowledge and attitude, and job groups; dental specialists had a more favorable knowledge and positive attitude than others (P < 0.001). CONCLUSION: We recommended developing more practical training programs in dental schools on cardiac diseases, and dental procedures requiring endocarditis prophylaxis and antibiotic diets.

Appropriate antibiotic use in dentistry: a review of the literature and clinical recommendations.

This article reviews the latest evidence on the use of antibiotics in dentistry, beginning with the risks of antibiotic use, which include Clostridioides difficile infection and antimicrobial resistance. The article then reviews the clinical practice guidelines for antibiotic prophylaxis for patients with prosthetic joints or at high risk for infective endocarditis. In the absence of established guidelines, the discussion also examines the published evidence on best practices for antibiotic prophylaxis with regard to other medical conditions (eg, kidney disease, cancer, or immunosuppression), dental extractions, minor oral surgical procedures, and implant placement, offering sample prescriptions for these situations. In addition, the current clinical practice guideline for antibiotic use in patients with endodontic infections is reviewed. Due to the alarming rates of antibiotic-resistant bacterial infections and increasing antimicrobial resistance, it is imperative that dentists use evidence-based guidelines and recommendations when prescribing antibiotics to prevent and treat oral infections.

Assessment of the current knowledge about infective endocarditis prevention among dental hygienists in Italy: A national survey.

OBJECTIVES: To date, there is a lack of data regarding the acceptance of the guidelines for infective endocarditis (IE) prevention among dentists in Italy, and similarly, there are no data on the understanding and compliance of those among dental hygienists (DH). Thus, we tried to assess the ability of DH to recognize and manage categories of patients at high risk of EI, to identify which dental procedures are at increased risk and to assess the level of knowledge of doses and how antibiotic prophylaxis should be administered in specific cases. METHODS: An anonymous questionnaire was prepared and made accessible online by sharing a Google Forms® link; general personal data and educational background information were collected to obtain a profile of the participants. RESULTS: A total of 362 DH answered to our web-based survey, showing a prevalent female percentage (86.7%) and the most represented age group of 30-39 years old (43.1%). Regarding the gender differences, there were not overall statistically significant differences; similarly, we did not find any differences regarding the overall number of wrong questions if considering the different ages of the participant and the year of graduation. Graduates in Northern Italy have mistaken fewer questions than graduates in other geographical areas. CONCLUSION: To the best of our knowledge, this is the largest survey about the knowledge of IE for DH ever performed. Because the overprescription of antibiotics contributes to the development of drug resistance, antibiotic stewardship should be at the forefront of patient care. Our data reflect the need for placing a greater emphasis on IE prophylaxis education in training and during continuing professional development events for DH.

Antibiotic prophylaxis before dental procedures to prevent infective endocarditis: a systematic review.

PURPOSE: Infective endocarditis (IE) is a severe bacterial infection. As a measure of prevention, the administration of antibiotic prophylaxis (AP) prior to dental procedures was recommended in the past. However, between 2007 and 2009, guidelines for IE prophylaxis changed all around the word, limiting or supporting the complete cessation of AP. It remains unclear whether AP is effective or not against IE. METHODS: We conducted a systematic review whether the administration of AP in adults before any dental procedure, compared to the non-administration of such drugs, has an effect on the risk of developing IE. We searched for studies in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via OVID, and EMBASE. Two different authors filtered articles independently and data extraction was performed based on a pre-defined protocol. RESULTS: The only cohort study meeting our criteria included patients at high-risk of IE. Analysis of the extracted data showed a non-significant decrease in the risk of IE when high-risk patients take AP prior to invasive dental procedures (RR 0.39, p-value 0.11). We did not find other studies including patients at low or moderate risk of IE. Qualitative evaluation of the excluded articles reveals diversity of results and suggests that most of the state-of-the-art articles are underpowered. CONCLUSIONS: Evidence to support or discourage the use of AP prior to dental procedures as a prevention for IE is very low. New high-quality studies are needed, even though such studies would require big settings and might not be immediately feasible.

Infective Endocarditis Antibiotic Prophylaxis: Review of the Evidence and Guidelines.

PURPOSE OF REVIEW: The question of antibiotic prophylaxis and its role in prevention of infective endocarditis (IE) remains controversial, with differing recommendations from international societies. The aim of this review was to compare and contrast current recommendations on antibiotic prophylaxis for IE by the American Heart Association (AHA), the European Society of Cardiology (ESC), and the National Institute for Health and Care Excellence (NICE) and highlight the evidence supporting these recommendations. RECENT FINDINGS: International guidelines for administration of antibiotic prophylaxis for prevention of IE are largely unchanged since 2009. Studies on the impact of the more restrictive antibiotic prophylaxis recommendations are conflicting, with several studies suggesting lack of adherence to current guidance from the ESC (2015), NICE (2016), and AHA (2021). The question of antibiotic prophylaxis in patients with IE remains controversial, with differing recommendations from international societies. Despite the change in guidelines more than 15 years ago, lack of adherence to current guidelines persists. Due to the lack of high-quality evidence and the conflicting results from observational studies along with the lack of randomized clinical trials, the question of whether to recommend antibiotic prophylaxis or not in certain patient populations remains unanswered and remains largely based on expert consensus opinion.

Recent infective endocarditis research findings suggest dentists prescribe prophylactic antibiotics for patients having a bicuspid aortic valve or mitral valve prolapse.

BACKGROUND: The scientific validity of the European Society of Cardiology's (ESC) infective endocarditis (IE) guidelines limiting provision of prophylactic antibiotics (AP) only to patients having cardiac anomalies (e.g., prosthetic valves) believed to place them at "high risk" of adverse events when undergoing high risk dental procedures (HRDP) is unclear. MATERIAL AND METHODS: A systematic review of studies conducted between 2017 and 2022 and catalogued in the PubMed database was undertaken to ascertain if this edict was associated with changes in IE incidence, development of infection in unprotected cardiac anomalies, developing infection and resultant adverse clinical outcomes. RESULTS: Retrieved were 19 published manuscripts, however of these, 16 were excluded because they did not bare upon the issues of concern. Among the three studies eligible for review were those in the Netherlands, Spain, and England. The results of the Dutch study denoted a significant increase in the incidence of IE cases over the projected historical trend (rate ratio: 1327, 95% CI 1.205-1.462; p<0.001) after the introduction of the ESC guidelines. The findings from the Spanish study evidenced the uniquely high in-hospital IE associated fatality rates suffered by patients having bicuspid aortic valves (BAV); 5.6% or mitral valve prolapse (MVP); 10%. The British study provided evidence that the incidence of fatal IE infection was significantly greater among an "intermediate risk" cohort of patients, (a group likely including those with BAC and MVP for which the ESC guidelines don't recommend AP), than among "high risk" patients (P = 0.002). CONCLUSIONS: Patients having either a BAV or MVP are at significant risk of developing IE and suffering serious sequelae including death. The ESC guidelines must reclassify these specific cardiac anomalies into the "high risk" category so that AP are recognized as being needed prior to provision of HRDP.

Prevention of Viridans Group Streptococcal Infective Endocarditis: A Scientific Statement From the American Heart Association.

BACKGROUND: In 2007, the American Heart Association published updated evidence-based guidelines on the recommended use of antibiotic prophylaxis to prevent viridans group streptococcal (VGS) infective endocarditis (IE) in cardiac patients undergoing invasive procedures. The 2007 guidelines significantly scaled back the underlying conditions for which antibiotic prophylaxis was recommended, leaving only 4 categories thought to confer the highest risk of adverse outcome. The purpose of this update is to examine interval evidence of the acceptance and impact of the 2007 recommendations on VGS IE and, if needed, to make revisions based on this evidence. METHODS AND RESULTS: A writing group was formed consisting of experts in prevention and treatment of infective endocarditis including members of the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics, in addition to the American Heart Association. MEDLINE database searches were done for English language articles on compliance with the recommendations in the 2007 guidelines and the frequency of and morbidity or mortality from VGS IE after publication of the 2007 guidelines. Overall, there was good general awareness of the 2007 guidelines but variable compliance with recommendations. There was no convincing evidence that VGS IE frequency, morbidity, or mortality has increased since 2007. CONCLUSIONS: On the basis of a review of the available evidence, there are no recommended changes to the 2007 VGS IE prevention guidelines. We continue to recommend VGS IE prophylaxis only for categories of patients at highest risk for adverse outcome while emphasizing the critical role of good oral health and regular access to dental care for all. Randomized controlled studies to determine whether antibiotic prophylaxis is effective against VGS IE are needed to further refine recommendations.

Infective Endocarditis Among High-risk Individuals Before and After the Cessation of Antibiotic Prophylaxis in Dentistry: A National Cohort Study.

BACKGROUND: A few years after the publication of the British guidelines, national recommendations were published by the Swedish Medical Products Agency in October 2012, promoting the cessation of antibiotic prophylaxis in dentistry for the prevention of infective endocarditis (IE). The aim of this study was to evaluate whether the incidence of oral streptococcal IE increased among high-risk individuals after October 2012. METHODS: This nationwide cohort study included all adult individuals (>17 years) living in Sweden from January 2008 to January 2018, with a diagnose code or surgical procedure code indicating high risk of IE. Cox proportional hazard models were performed to calculate adjusted ratios of oral streptococcal IE before and after October 2012 between high-risk individuals and references. RESULTS: This study found no increased incidence of oral streptococcal IE among high-risk individuals during the 5 years after the cessation, compared with before. Hazard rate ratios were 15.4 (95% confidence interval [CI]: 8.3-28.5) before and 20.7 (95% CI: 10.0-42.7) after October 2012 for prevalent high-risk individuals. Corresponding ratios for incident high-risk individuals were 66.8 (95% CI: 28.7-155.6) and 44.6 (95% CI: 22.9-86.9). Point estimates for interaction with time period were 1.4 (95% CI: .6-3.5) and 0.8 (95% CI: .5-1.3) for prevalent and incident high-risk individuals, respectively. CONCLUSION: The results suggest that the current Swedish recommendation not to administer antibiotic prophylaxis for the prevention of IE in dentistry has not led to an increased incidence of oral streptococcal IE among high-risk individuals.

Dental care of patients scheduled for cardiovascular surgery: Which protocols should be followed?

Dental extraction of abscessed or infected teeth before cardiac operation is frequently advocated to lower the risk of infections, especially infective endocarditis. The scientific evidence that supports dental procedures before cardio-valvular surgery is, however, limited. The aim of the present paper was to explore whether there are any protocols for patients needing dental treatment before cardiac surgery. Moreover, we have discussed the real life challenges encountered in the management of such patients.

Prevention of Infective Endocarditis of Oral Origin in Children: A Call for Pediatric Dentists-Pediatric Cardiologists' Collaboration in Egypt.

AIM: To assess knowledge and practices of some Egyptian pediatric dentists and pediatric cardiologists/cardiac surgeons regarding prevention of infective endocarditis (IE) from oral origin in children. MATERIALS AND METHODS: Pediatric dentists or pediatric cardiologists/cardiac surgeons having their practice in Egypt were conveniently selected. An online questionnaire was constructed for each specialty practitioner in English using a web-based platform. Each survey tool collected data about demographics, knowledge, and practices concerning the prevention of IE of oral origin. Surveys were disseminated to potential respondents using direct messaging or posting surveys' links on high-traffic areas (blogs, groups, or pages) of commonly known social media platforms. RESULTS: Two-hundred and thirty-nine pediatric dentists and 71 pediatric cardiologists/cardiac surgeons' responses were included in analysis. Some shortage in oral health knowledge and deviations in management protocol from known guidelines were evident in cardiologists' responses, whereas 66.2 and 64.8% reported encountering IE of oral origin or canceling a cardiac surgery due to oral infection, respectively. Most pediatric dentists (65.7%) rely on physician referral before managing children at risk of IE despite following recognized guidelines for IE prevention which may reflect difficulty in understanding such guidelines. Ninety percent of children with heart diseases visit a dentist due to oral complaint and not for checkup. CONCLUSION: Identification of disparities and pitfalls in management of children with heart diseases, if appropriately addressed by pediatric dentists and cardiologists, may reduce the risk of IE from an oral origin. CLINICAL SIGNIFICANCE: Health education of both specialists and development of national guidelines based on national epidemiology and clinical experience of cardiologists are strongly needed to decrease oral disease burden, allow for a consensus of patient management, and minimize the need for cross-referral, thus facilitating dental management without undue delays.

[Prevention of endocarditis in dentistry]. / Profilaktyka infekcyjnego zapalenia wsierdzia w stomatologii.

Infective endocarditis (IE) is an inflammatory process caused by the implantation of bacteria on the heart valves or wall insertion. Bacteria leading to IE may be caused by oral procedures, such as tooth extractions, periodontal treatments, root canal treatment, scaling and tooth implantation. Antibiotic prophylaxis should only be used in accordance with the recommendations in the high-risk group of IEs, by providing the appropriate antibiotic 30-60 min. Before the planned dental treatment. In addition to appropriate antibiotic prophylaxis, special emphasis should be placed on improving dental care, regular check-ups and planned dental treatment as well as on maintaining proper oral hygiene.

[Antibiotic prophylaxis for infective endocarditis: current approaches].

This review addresses current views on prevention of infectious endocarditis (IE). History of establishing the concept of antibacterial prophylaxis (ABP), major approaches, and substantiation of changes in ABP in recent years are described. Recent international and national guidelines are highlighted, specifically, guidelines of the European Society of Cardiologists, American Heart Association/American College of Cardiology, and the Japanese Circulation Society. The review presents critical evaluation of previously approved international guidelines, including analysis of the effect of partial or complete ABP restriction on IE morbidity and incidence of complications. Special attention is paid to awareness of practitioners, particularly dentists, about ABP issues in their practice. Aspects of validity and key features of preventive approaches in implanting cardiac electronic devices and transcatheter aortic valve implantation are discussed.

Review of Guidelines for Dental Antibiotic Prophylaxis for Prevention of Endocarditis and Prosthetic Joint Infections and Need for Dental Stewardship.

Dentists prescribe 10% of all outpatient antibiotic prescriptions, writing more than 25.7 million prescriptions per year. Many are for prophylaxis in patients with prosthetic joint replacements; the American Dental Society states that "in general," prophylactic antibiotics are not recommended to prevent prosthetic joint infections. Orthopedic surgeons are concerned with the risk of implant infections following a dental procedure and, therefore, see high value and low risk in recommending prophylaxis. Patients are "stuck in the middle," with conflicting recommendations from orthopedic surgeons (OS) and dentists. Unnecessary prophylaxis and fear of lawsuits amongst private practice dentists and OS has not been addressed. We review The American Heart Association/American College of Cardiology, American Dental Association, and American Association of Orthopedic Surgeons' guidelines on dental antibiotic prophylaxis for the prevention of endocarditis and prosthetic joint infections. We provide experience on how to engage private-practice dentists and OS in dental stewardship using a community-based program.

Investigation of the impact of the NICE guidelines regarding antibiotic prophylaxis during invasive dental procedures on the incidence of infective endocarditis in England: an electronic health records study.

BACKGROUND: Infective endocarditis is an uncommon but serious infection, where evidence for giving antibiotic prophylaxis before invasive dental procedures is inconclusive. In England, antibiotic prophylaxis was offered routinely to patients at risk of infective endocarditis until March 2008, when new guidelines aimed at reducing unnecessary antibiotic use were issued. We investigated whether changes in infective endocarditis incidence could be detected using electronic health records, assessing the impact of inclusion criteria/statistical model choice on inferences about the timing/type of any change. METHODS: Using national data from Hospital Episode Statistics covering 1998-2017, we modelled trends in infective endocarditis incidence using three different sets of inclusion criteria plus a range of regression models, identifying the most likely date for a change in trends if evidence for one existed. We also modelled trends in the proportions of different organism groups identified during infection episodes, using secondary diagnosis codes and data from national laboratory records. Lastly, we applied non-parametric local smoothing to visually inspect any changes in trend around the guideline change date. RESULTS: Infective endocarditis incidence increased markedly over the study (22.2-41.3 per million population in 1998 to 42.0-67.7 in 2017 depending on inclusion criteria). The most likely dates for a change in incidence trends ranged from September 2001 (uncertainty interval August 2000-May 2003) to May 2015 (March 1999-January 2016), depending on inclusion criteria and statistical model used. For the proportion of infective endocarditis cases associated with streptococci, the most likely change points ranged from October 2008 (March 2006-April 2010) to August 2015 (September 2013-November 2015), with those associated with oral streptococci decreasing in proportion after the change point. Smoothed trends showed no notable changes in trend around the guideline date. CONCLUSIONS: Infective endocarditis incidence has increased rapidly in England, though we did not detect any change in trends directly following the updated guidelines for antibiotic prophylaxis, either overall or in cases associated with oral streptococci. Estimates of when changes occurred were sensitive to inclusion criteria and statistical model choice, demonstrating the need for caution in interpreting single models when using large datasets. More research is needed to explore the factors behind this increase.

The epidemiological and clinical features of odontogenic infective endocarditis.

Antibiotic prophylaxis (AP) of infective endocarditis (IE) in dental practice is a controversial topic. We evaluated the characteristics of the odontogenic IE and assessed the practice and sources of information pertaining to the topic utilized by the Croatian dentists. We conducted a retrospective review of consecutive medical charts of adult patients with IE, admitted to the University Hospital for Infectious Diseases in Zagreb, Croatia, between January 2007 and December 2017. In addition, a cross-sectional, self-reporting questionnaire survey was conducted with participation of 348 Croatian dentists. Of the 811 admissions for suspected IE (40.3% of all Croatian and 92.1% of all Zagreb hospitals), 386 patients were confirmed as definite IE: 68 with odontogenic IE and 318 with IE of other origin. Their first hospital admissions were analyzed. Definite odontogenic IE was defined as a positive echocardiographic result in conjunction with two separate positive blood cultures showing exclusive oral cavity pathogen or Streptococcus viridans associated with current or recent (< 1 month) dental, periodontal, or oral cavity infection. The annual number of new odontogenic IE patients appeared constant over time. In 91.2% of the cases, odontogenic IE was not preceded by a dental procedure; poor oral health was found in 51.5% of patients, and 47.1% had no cardiac condition that increases the IE risk. In-hospital mortality was 5.1% with conservative treatment and 4.5% with cardiac surgery and was much lower for odontogenic IE than in non-odontogenic IE (14.6% and 34.4%, respectively). An increasing number of admissions for non-odontogenic IE were observed in parallel with an increasing number of staphylococcal IE. Surveyed dentists (500 invited, 69.6% responded) were aware of the AP recommendations, but were largely reluctant to treat patients at risk. In people with poor oral health, AP should be considered regardless of cardiac risk factors. Improvement of oral health should be the cornerstone of odontogenic IE prevention.

Incidence of infective endocarditis in patients considered at moderate risk.

AIMS: Stratification of patients at risk of infective endocarditis (IE) remains a cornerstone in guidance of prophylactic strategies of IE. However, little attention has been given to patients considered at moderate risk. METHODS AND RESULTS: Using Danish nationwide registries, we assessed the risk of IE in patients with aortic and mitral valve disorders, a cardiac implantable electronic device (CIED), or hypertrophic cardiomyopathy (HCM) and compared these patient groups with (i) controls from the background population using risk-set matching and (ii) a high-risk population (prosthetic heart valve). Cumulative incidence plots and multivariable adjusted Cox proportional hazard analysis were used to compare risk of IE between risk groups. We identified 83 453 patients with aortic or mitral valve disorder, 50 828 with a CIED, and 3620 with HCM. The cumulative risk of IE after 10 years was 0.9% in valve disorder, 1.3% in CIED, and 0.5% in HCM patients. Compared with the background population, valve disorder, CIED, and HCM carried a higher associated risk of IE, hazard ratio (HR) = 8.75 [95% confidence interval (CI) 6.36-12.02], HR = 6.63 (95% CI 4.41-9.96), and HR = 6.57 (95% CI 2.33-18.56), respectively. All three study groups were associated with a lower risk of IE compared with high-risk patients, HR = 0.27 (95% CI 0.23-0.32) for valve disorder, HR = 0.28 (95% CI 0.23-0.33) for CIED, and HR = 0.13 (95% CI 0.06-0.29) for HCM. CONCLUSIONS: Heart valve disorder, CIED, and patients with HCM were associated with a higher risk of IE compared with the background population but have a lower associated risk of IE compared with high-risk patients.