External validation of the 2023 Duke-International Society for Cardiovascular Infectious Diseases (ISCVID) diagnostic criteria for infective endocarditis

Presenter: Thomas W. van der Vaart, MD, Academic Medical Center, Amsterdam, Netherlands

For the clinical diagnosis of infective endocarditis, the 2023 Duke-International Society for Cardiovascular Infectious Diseases (ISCVID) criteria1 represent a significant advance, according to Thomas W. van der Vaart, MD, Internal Medicine Resident, Academic Medical Center Amsterdam, Amsterdam, Noord-Holland, Netherlands. Compared with earlier criteria,2–5 the Duke-ISCVID criteria are more sensitive and equally specific, and are also better than the new (2023) European Society of Cardiology (ESC) criteria,6 van der Vaart said in an ID Week 2023 oral presentation.

The challenge of infective endocarditis diagnosis is a very difficult one, he observed, and has led to a series of diagnostic standards over the last 42 years.

The prior criteria, van der Vaart noted further, have gone through stages of development, publication, and subsequent validation through external studies. It has been urged1 that the current 2023 Duke-ISCVID criteria undergo similar external validation studies. Toward that end, van der Vaart and colleagues compared the diagnostic accuracy of the new criteria with the 2000 modified Duke criteria,4 the 2015 ESC criteria,5 and a clinically adjudicated reference standard by a panel of international experts on infective endocarditis.

Van der Vaart pointed out that there is no available gold standard for diagnosing infective endocarditis, and that the best alternative is an adjudication panel of experts. The researchers assembled a team of 12 international infective endocarditis experts, giving them standardized case report forms and asking, “Does this patient have infective endocarditis” based on clinical experience and gestalt. All individual cases were adjudicated by 2 experts, with a third adjudicator brought in when the first 2 disagreed.

Their retrospective analysis of a prospective registry (2016–2021) included a study population consisting of consecutively enrolled adult patients referred to the endocarditis team of the Amsterdam University Medical Center for suspected infective endocarditis and discussed by the infective endocarditis team.

The panel of experts assigned a final diagnosis, which served as the reference standard. Investigators compared the definite classification of the 2023 Duke-ISCVID criteria against this reference standard and compared them with the 2000 modified Duke and the 2015 ESC criteria. They also evaluated the accuracy of the new criteria, and they quantified the added value of the proposed changes to the criteria. Lastly, they performed sensitivity analyses in patients who underwent cardiac surgery and patients who underwent transesophageal echocardiography.

Among the 595 patients with suspected infective endocarditis who were included, 399 (67%) were adjudicated as having infective endocarditis, and the other 196 (33%) were adjudicated as not having infective endocarditis. The rate of agreement between adjudicators was 88% (Cohen’s kappa 0.72).

Of the entire group, 217 (36%) had a prosthetic heart valve, 152 (26%) had native valve disease, 103 (17%) had a cardiac implantable electronic device, and 8 (1%) were active injection drug users. Imaging rates were transthoracic echocardiography 95%, transesophageal echocardiography 75%, positron-emission tomography-computed tomography 56%, and cardiac computed tomography 56%, van der Vaart stated.

The 2023 Duke-ISCVID criteria had greater sensitivity (84.2%) than the 2000 modified Duke criteria (74.9%, P < .001) and the 2015 ESC criteria (80.0%, P < .001) without significant loss of specificity (2023 Duke-ISCVID 93.9%, 2000 modified Duke 94.9% [P = .16], 2015 ESC 93.9%). Sensitivity analyses based on the findings of transesophageal echocardiography and on confirmation by surgery and pathology gave similar results, again without losing sensitivity.

What caused the improvement for the 2023 Duke-ISCVID criteria? New imaging and to a lesser degree major microbiological changes had the most impact toward gains over the 2000 modified Duke criteria, van der Vaart said.

This year (2023), the ESC has published new criteria,6 and van der Vaart offered a “last minute” comparison with the 2023 Duke-ISCVID criteria. The main difference, he observed, is that the new ESC criteria have not changed their major microbiology criteria but have added spondylodiscitis as a vascular phenomenon. The sensitivity of the new 2023 ESC criteria is 82.7% (vs 84.2% for Duke-ISCVID, P = .014) and the specificity is 92.3% (vs 93.9%, P = .083).

Concluding, van der Vaart stated, “In this cohort, the 2023 Duke-ISCVID criteria represent a significant advance in the diagnostic classification of patients suspected of infective endocarditis, including over the new 2023 ESC criteria. The Duke-ISCVID Criteria are ready for use in research and in clinical practice.”

Disclosures. Dr. Van der Vaart had no disclosures.

References

  1. Fowler VG, Durack DT, Selton-Suty C, et al. The 2023 Duke-International Society for Cardiovascular Infectious Diseases Criteria for Infective Endocarditis: Updating the Modified Duke Criteria. Clin Infect Dis 2023; 77(4):518–526. doi:10.1093/cid/ciad271. Erratum in: Clin Infect Dis 2023 Oct 13;77(8):1222.
  2. von Reyn FC, Arbeit RD, Friedland GH, Crumpacker CS 3rd. Criteria for the diagnosis of infective endocarditis. Clin Infect Dis 1994; 19(2):368–370. doi:10.1093/clinids/19.2.368
  3. Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med 1994; 96(3):200–209. doi:10.1016/0002-9343(94)90143-0
  4. Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis 2000; 30(4):633–638. doi:10.1086/313753
  5. Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015; 36(44):3075–3128. doi:10.1093/eurheartj/ehv319
  6. Delgado V, Ajmone Marsan N, de Waha S, et al. 2023 ESC Guidelines for the management of endocarditis [published correction appears in Eur Heart J 2023 Sep 20;:]. Eur Heart J 2023; 44(39):3948–4042. doi:10.1093/eurheartj/ehad193

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