Overuse of Transthoracic Echocardiography in the Diagnosis of Native Valve Endocarditis

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Abstract
INFECTIVE ENDOCARDITIS (IE) is a disease with high mortality, which requires early diagnosis to give appropriate treatment. Early identification of patients at risk for IE continues to present a challenge because clinical findings can vary widely.1 To aid diagnosis, formal criteria were published by Pelletier and Petersdorf2 in 1977. In 1981, Von Reyn et al3 modified these criteria and proposed strict case definitions, generating 4 categories: definite (based on pathological findings), probable, possible, and rejected (see Appendix 1 of Von Reyn et al3). During the 1980s, transthoracic echocardiography (TTE) became widely used in the evaluation of valvular abnormalities, and the technology has since gained sensitivity for identifying vegetations and valvular regurgitation. In 1994, Durack et al4 proposed the addition of TTE findings to the diagnostic criteria of endocarditis (referred to as the Duke criteria) (see Appendixes 2 and 3 of Durack et al4). In the ensuing years, several groups have confirmed the increased sensitivity of the Duke criteria as compared with the older Von Reyn criteria. Most of these later studies have been retrospective, and have used pathological specimens or autopsy results to define the positive cases.5-15