Abstract Background Infective Endocarditis (IE) remains a life-threatening condition with high morbidity and mortality, requiring early and accurate diagnosis for optimal management. While the European Society of Cardiology (ESC) guidelines provide a structured approach to diagnosis, real-world adherence to these recommendations is often inconsistent. In particular, patients classified as "Possible" IE may not undergo the full spectrum of advanced imaging and microbiological testing, leading to diagnostic uncertainty and potentially inappropriate treatment decisions. This study evaluates whether the recommended diagnostic approach is being adequately applied in patients with suspected IE and highlights key areas for improvement. Methods We conducted a retrospective, single-center study including 90 patients diagnosed with IE between 2017 and 2022. Patients were classified as "Definite," "Possible," or "Rejected" IE based on the ESC criteria. For those classified as "Possible" IE, we assessed the utilization of advanced imaging (PET-CT, cardiac CT) and serological testing for atypical pathogens, as recommended by guidelines. Results Among the 90 patients (68.9% male, median age 69.9 ± 12.6 years), 86.7% were classified as "Definite" IE and 13.3% as "Possible" IE. Within the "Possible" group, only one patient (8.3%) underwent PET-CT and cardiac CT, and serological testing for atypical pathogens was performed in just five cases (41.7%). These patients were admitted to Cardiology (58.3%), Internal Medicine (25.0%), Neurology (8.3%), and the Intensive Care Unit (8.3%). Despite no statistically significant difference in in-hospital mortality, stroke, atrioventricular block, or sepsis between the "Definite" and "Possible" groups, the underutilization of diagnostic tools raises concerns about missed or misclassified cases, potentially leading to inadequate treatment strategies. Conclusion This study underscores a critical gap in the diagnostic workup of patients with suspected IE, particularly in the underuse of multimodal imaging and microbiological testing. Given that IE is a high-risk condition with severe outcomes, improving adherence to guideline-directed diagnostic strategies is essential to avoid missed diagnoses and ensure appropriate management. The findings reinforce the need for a multidisciplinary Endocarditis Team to standardize diagnostic pathways and facilitate timely, evidence-based decision-making. A systematic, comprehensive diagnostic approach—leveraging advanced imaging and targeted microbiological investigations—may significantly enhance IE detection, classification, and patient outcomes.
Mateus et al. (Sat,) studied this question.