Guidelines in review: Comparison of ESC and AHA guidance for the diagnosis and management of infective endocarditis in adults

Abstract

Over recent years, new evidence has led a rethinking of the available guidance on the diagnosis and management of infective endocarditis (IE). This review compares the most recently available guidance provided by the American Heart Association (AHA) IE Writing Committee, and the Task Force for the management of IE of the European Society of Cardiology (ESC). This represents the sixth of a new series of comparative guidelines review published in the Journal.

Over recent years, new evidence has led to a rethink of the available guidance on the diagnosis and management of infective endocarditis (IE). This review compares the most recently available recommendations provided by the American Heart Association (AHA) IE Writing Committee, and the Task Force for the management of IE of the European Society of Cardiology (ESC).1,2 Class (I, II or III) and level of evidence (A, B or C) are provided for each recommendation where given by the guidelines (Tables 1, 2, 3; Figures 1, 2). As in previous comparative guidelines reviews published in the Journal,3–7 this review focuses on the role of imaging in the evaluation and management of patients with suspected IE.

Table 1.

Indications for echocardiography in patients with suspected infective endocarditis

*According to the AHA scientific statement, TEE is preferred over TTE, but the latter should be performed if TEE is not immediately available. TTE may be sufficient in small children

^†AHA statement also suggests TEE as first-line test in patients with a prosthetic valve and suspected IE

^‡In this clinical scenario, the AHA statement recommends repeating the TEE in 3 to 5 days or sooner

^§ESC guidelines stipulate that the timing and mode (TTE or TEE) of repeat test depend on initial findings, microorganism type, and initial response to therapy

Table 2.

indications for non-invasive imaging in cardiac device-related infective endocarditis (CDREI)

Table 3.

Role of CT, MRI, radionuclide imaging and angiography in the assessment of IE patients

*These proposed indications are discussed in the guidelines but neither the ESC guidelines nor the AHA scientific statement give specific or formal recommendation

^†The AHA statement recommends that, in IE patients with suspected metastatic foci of infection, the choice of diagnostic technique (ultrasonography, CT or MRI) should be individualised for each patient (Class I; LOE, C)

^‡Although there is no specific recommendation, the ESC guidelines state that patients with suspected splenic complications should be evaluated by CT, MRI or ultrasound

^§The AHA statement recognises that more studies are needed to determine the role of ¹⁸F-FDG PET/CT imaging in the diagnosis and management of patients with IE, and highlights evidence on the usefulness of this technique for the detection of peripheral emboli and other extracardiac complications

Figure 1.

ESC and AHA recommendations for the initial assessment of patients with clinically suspected infective endocarditis using echocardiography

Figure 2.

Role of advanced imaging in the assessment of patients with infective endocarditis. CTA, computed tomographic angiography; ¹⁸F-FDG, 18-fluorodeoxyglucose; MRA, magnetic resonance angiography; MRI, magnetic resonance imaging; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography

Abbreviations

CTCA

Computed tomographic coronary angiography

CDRIE

Cardiac device-related infective endocarditis

DSA

Digital subtraction angiography

¹⁸F-FDG

18-fluorodeoxyglucose

IE

Infective endocarditis

LOE

Level of evidence

MRI

Magnetic resonance imaging

MRA

Magnetic resonance angiography

NSER

No specific equivalent recommendation

PET/CT

Positron emission tomography/computed tomography

TEE

Transesophageal echocardiography

TTE

Transthoracic echocardiography