The Gender Gap in Heart Health: Are Women Winning the Battle Against Endocarditis?
"New research sheds light on why women with congenital heart disease may have a lower risk of infective endocarditis, highlighting the importance of oral hygiene and disease awareness."
Infective endocarditis (IE), an infection of the heart's inner lining or valves, poses a significant threat to individuals with congenital heart disease (CHD). While CHD increases the overall risk of IE, a curious disparity exists: women with CHD experience a 50% lower risk of IE compared to their male counterparts. This intriguing gender gap has prompted researchers to investigate potential explanations, with a spotlight on differences in oral hygiene practices.
Poor oral hygiene is a well-known risk factor for IE. The accumulation of plaque and calculus can lead to gingivitis and create opportunities for bacteria to enter the bloodstream during everyday activities like brushing. Current IE prevention guidelines emphasize the importance of maintaining optimal oral health, sometimes even more so than prophylactic antibiotics for dental procedures.
A recent study published in Open Heart sought to explore this gender-related difference by assessing self-reported dental hygiene habits and IE knowledge among adults with CHD. The findings offer valuable insights into the factors that may contribute to the lower IE incidence in women and underscore the significance of patient education and tailored preventative strategies.
Growing Endocarditis Burden
A nationwide case-control study reported an 8.5% lifetime incidence of infective endocarditis among patients with congenital heart disease. Incidence correlated with age, and the number of cases is expected to increase as this population expands and grows older. The CDC reports that babies born with congenital heart defects are living longer and healthier lives, although medical care can be costly.
Imaging and Diagnostic Limits
Echocardiography remains the cornerstone of initial infective endocarditis evaluation, but its limitations become important in complex cases. The modified Duke criteria are broadly applicable, yet congenital heart disease requires attention to features such as shunt-related defects, conduits, and percutaneous pulmonary stents and devices. Updated approaches now include advanced multimodality imaging, non-culture-based pathogen identification, and updated case definitions.
From Fatal Disease to Treatable Condition
Historical reviews describe infective endocarditis as a fatal disease three generations ago. Advances in diagnostic techniques, particularly echocardiography, cardiac surgery during active infection, and antibiotic prophylaxis guidelines for interventional procedures changed its management. Historical accounts also identify congenital heart disease, rheumatic fever, major dental treatment, open-heart surgery, and genitourinary procedures as conditions or exposures associated with valve-infection risk.
Decoding the Disparity: Oral Hygiene Habits and IE Knowledge
The study, conducted at the Center for Congenital Heart Disease of the University Hospital Inselspital in Bern, Switzerland, involved 187 adults with CHD at increased risk of IE. Participants completed a questionnaire assessing their knowledge of IE and their self-reported oral hygiene practices, including the frequency of tooth brushing and dental check-ups. Good oral hygiene was defined as brushing teeth twice daily and having a dental check-up at least once a year, aligning with American Dental Association recommendations.
- Knowledge is Key: Individuals with higher IE knowledge scores were more likely to report good oral hygiene practices.
- Gender Matters: Women were significantly more likely than men to practice recommended dental care.
- No Difference in Knowledge: Interestingly, there was no significant difference in IE knowledge scores between men and women.
- Overall Good Hygiene: A substantial 67% of the participants reported maintaining good oral hygiene.
Rising Risk in Adult CHD
Recent research continues to identify infective endocarditis as a major cause of morbidity and mortality in people with congenital heart disease. Advances in medical and surgical care have produced a growing population of adults with congenital heart disease who carry a substantially higher lifetime risk of infective endocarditis than the general population. Reviews also highlight patient-related factors, including limited awareness and learning disabilities, as contributors to risk.
Persistent Risk Despite Repair
Endocarditis remains a major concern in patients with congenital heart disease whether the condition is unrepaired, palliated, or corrected. One Circulation review reported an incidence of 11 per 100,000 person-years in adults with congenital heart disease, compared with 1.5 to 6.0 per 100,000 patient-years in the general population. Another review states that congenital heart disease involving high-velocity blood-flow jets or artificial material carries the highest risk, including after palliative or definitive surgery.
Comparing CHD and Non-CHD Outcomes
Patients with congenital heart disease form a high-risk subgroup for infective endocarditis and may require tailored prevention and treatment strategies. A 2024 nationwide study noted that comprehensive comparisons of endocarditis characteristics and outcomes in patients with and without congenital heart disease, including children, remain sparse. A 2025 study specifically sought to compare incidence, hospital outcomes, and costs in children and adults with endocarditis with and without congenital heart disease.
Empowering Patients Through Education and Awareness
These findings reinforce the importance of patient education in preventing IE. By increasing awareness and understanding of the disease, healthcare professionals can empower individuals with CHD to take proactive steps in maintaining their oral health. While the study highlights a potential gender-related difference in oral hygiene practices, it emphasizes the need for tailored interventions that address the specific needs and behaviors of all patients at risk for IE. Further research is needed to explore the underlying reasons for these gender differences and to develop effective strategies for promoting optimal oral hygiene in both men and women with CHD.
Specialized Care for a Growing Population
The population of adults with congenital heart disease is growing, and it remains at increased risk for infective endocarditis. Susceptibility is linked to uncorrected native defects, previous repairs involving patches or prosthetic materials, residual shunts, and percutaneously implanted devices. These features support continued development of specialized prevention, diagnosis, and management strategies for adult congenital heart disease.