Infective endocarditis can be a difficult diagnosis to make. However, a thorough history, careful physical exam, and application of validated diagnostic criteria can improve diagnostic accuracy. Echocardiography (TTE and TEE) is an extremely useful tool in the diagnosis and prognosis of IE, but it needs to be used appropriately. In general, TEE is more sensitive and specific compare to TTE but is also more invasive and associated with a small but definite complication risk. Patient selection for and timing of echocardiography should be based on stratifying patients into clinical risk categories (high vs. low) and assessing the likelihood of IE (high, intermediate, and low). Patients with high clinical risk should undergo echo on a high-priority basis. Patients with low clinical risk but a high likelihood of IE should be empirically treated and an echo performed not for diagnostic purposes but to guide prognosis and treatment. Patients with low clinical risk and low clinical likelihood need not routinely undergo echocardiography, whereas those with low clinical risk and intermediate clinical likelihood should undergo echocar-diography to help clarify the diagnosis. We should be particularly vigilant about the diagnosis of IE in patients with persistent S. aureus bac-teremia and patients with prosthetic heart valves. In these patients, we recommend a low threshold for echocardiography (TTE and TEE). TEE has proven to be very useful and should be performed in the majority of these patients.

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