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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 February 2, 2021 e157 CLINICAL STATEMENTS AND GUIDELINES

systems and non–culture-based technology. In the 10% of patients with culture-negative endocarditis, serological testing or advanced laboratory diagnostics (eg, polymerase chain reaction) may be helpful to identify the etiologic agent.1,42,75–78 2.	 The recent onset of new or increased left-sided valve regurgitation, detected by the presence of a new or louder murmur followed by TTE confirmation, may be attributable to endocarditis, so it is prudent to obtain blood culture samples to exclude this diagnosis. 3.	 The Modified Duke Criteria (Tables 24 and 25) have been well validated by comparison with surgical or autopsy findings and in the clinical outcomes of numerous studies involving a wide spectrum of patients, including children, the elderly, prosthetic valve recipients, injection drug users, and non–drug users, as well as patients in both primary- and tertiary-care settings. About three-fourths of patients with IE are diagnosed within 30 days of the onset of infection, so classic clinical features of IE, such as embolic or vasculitic skin lesions, renal disease caused by immune complex deposition, and immunologic abnormalities, are often absent. In these cases, maintaining a high level of clinical suspicion with regard to the possibility of IE in patients who are susceptible is paramount.4,6–10 4.	 The diagnosis of IE can still be difficult and is frequently delayed, which may cause progressive and potentially irreparable structural damage to the heart and other organ systems secondary to vascular–embolic and immunologically mediated events. Additionally, stroke (16.9%), embolization other than stroke (22.6%), HF (32.3%), intracardiac abscess (14.4%), and the need for surgical therapy (48.2%) remain common. Patients with suspected IE are most optimally managed in an environment that coordinates the management of specialists who are well attuned to the various organ systems, pathological processes, and potential treatment

Table 24.  Diagnosis of IE According to the Proposed Modified Duke Criteria

Definite IE Pathological criteria Microorganisms demonstrated by culture or histological examination

of a vegetation, a vegetation that has embolized, or an intracardiac abscess specimen; or Pathological lesions: Vegetation or intracardiac abscess confirmed by

histological examination showing active endocarditis Clinical criteria 2 major criteria; or 1 major criterion and 3 minor criteria; or 5 minor criteria Possible IE 1 major criterion and 1 minor criterion; or 3 minor criteria Rejected Firm alternative diagnosis explaining evidence of IE; or Resolution of IE syndrome with antibiotic therapy for <4 d; or No pathological evidence of IE at surgery or autopsy, with antibiotic

therapy for <4 d; or Does not meet criteria for possible IE as listed above IE indicates infective endocarditis. Adapted from Durack DT, et al,2 and Li JS, et al.4 Table 25.  Major and Minor Criteria in the Modified Duke Criteria for the Diagnosis of IE

Major criteria Blood culture positive for IE Typical microorganisms consistent with IE from 2 separate blood

cultures: Viridans streptococci, Streptococcus bovis, HACEK group

(Haemophilus spp, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella spp, and Kingella kingae), S. aureus; or community-acquired enterococci, in the absence of a primary focus; or Microorganisms consistent with IE from persistently positive blood

culture results, defined as follows: At least 2 positive culture results of blood samples drawn 12 h

apart; or All of 3 or most of ≥4 separate culture samples of blood (with first

and last samples drawn at least 1 h apart) Single positive blood culture result for Coxiella burnetii or antiphase

I IgG antibody titer >1:800 Evidence of endocardial involvement Echocardiogram positive for IE defined as follows: Oscillating intracardiac mass on valve or supporting structures, in the

path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation Abscess; or New partial dehiscence of prosthetic valve New valvular regurgitation (worsening or changing of preexisting

murmur not sufficient) Minor criteria Predisposition, predisposing heart condition, or injection drug use Fever, temperature >38°C (100.4°F) Vascular phenomena, major arterial emboli, septic pulmonary infarcts,

mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions Immunological phenomena: glomerulonephritis, Osler’s nodes, Roth’s

spots, and rheumatoid factor Microbiological evidence: positive blood culture but does not meet

a major criterion as noted above* or serological evidence of active infection with organism consistent with IE *Excludes single positive cultures for coagulase-negative staphylococci and organisms that do not cause IE. IE indicates infective endocarditis; IgG, immunoglobulin G; and spp, species.

Adapted from Durack DT, et al,2 and Kupferwasser LI, et al.3

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