Diagnostic performance of 2023 endocarditis criteria in patients with and without cardiac implantable electronic devices

BACKGROUND: The European Society of Cardiology (ESC) diagnostic criteria for infective endocarditis (IE) were updated in 2023. Using a prospective multicentre cohort of patients treated for IE, we compared the performance of the 2023 ESC classification to that of 2015 ESC, 2019 European Heart Rhythm Association (EHRA) and 2023 Duke-International Society for Cardiovascular Infectious Diseases (ISCVID) classifications in patients with or without cardiac implantable electronic devices (CIEDs). METHODS: A total of 1180 patients treated for IE between January 2017 and October 2022 were categorised as having either definite or possible/rejected IE within each classification. The gold standard diagnosis of IE was independently adjudicated by experts as 'certain' or not. Definite and 'certain' cases of IE were cross-tabulated to calculate sensitivity, specificity and accuracy.Suspicion of lead IE was defined by specific anatomical or metabolic features of cardiac lead infection on imaging; or by pulmonary embolism without valvular vegetation; or by positive culture of a lead extracted during open-heart surgery. RESULTS: In the 269 patients with CIEDs, 208 (77.3%) were adjudicated as 'certain IE'; 2023 Duke-ISCVID and 2023 ESC classifications achieved higher sensitivity (97.1% and 93.8%, respectively) but markedly lower specificity (31.1% and 41.0%, respectively) than 2015 ESC and 2019 EHRA classifications.In the 159 patients with CIEDs and lead IE (78.6% 'certain IE'), while sensitivity remained high for all classifications, specificity dropped for 2023 Duke-ISCVID and 2023 ESC classifications (11.8% and 32.4%, respectively), but not for 2019 EHRA classification (67.6%).In the 911 patients without CIEDs (81.0% 'certain IE'), sensitivity was higher than 96% for all classifications and specificity was 55.5%, 52.6% and 48.0% for 2015 ESC, 2023 Duke-ISCVID and 2023 ESC classifications, respectively. CONCLUSIONS: The 2023 ESC and 2023 Duke-ISCVID classifications had a higher sensitivity but a lower specificity than the 2015 ESC classification in patients with CIEDs, especially among those with lead IE. In patients with CIEDs, the 2019 EHRA classification was the most accurate.