Prescriptive appropriateness of echocardiography for the diagnosis of infective endocarditis: an 11-year observational study

Transthoracic (TTE) and transoesophageal echocardiography (TEE) are fundamental tools in diagnosing infective endocarditis (IE). Although IE remains rare, ultrasound (US) requests are increasing. No long-term data exist regarding the appropriateness of US prescriptions for IE following the 2017 Appropriate Use Criteria (AUC) for Multimodality Imaging in Valvular Heart Disease.

US requests for suspected IE from September 2013 to June 2024 were reviewed. Patient records were retrieved electronically. Appropriateness was assessed using the 2017 AUC, the 2015 ESC Guidelines for IE management, and the 2013 Guidelines for TEE performance. Over 11 years, 2461 US requests, each referring to a unique hospitalized patient, were analysed. Most patients were males (60.5%), mean age 64 ± 17 years. Positive blood cultures were found in 41.8%, and IE was diagnosed in 10.6%, with a mortality rate of 7.6%. Overall, 1559 (63.4%) US requests were deemed inappropriate, with no significant change after guideline publication (P = 0.078). Specifically, 1402 (64.8%) TTE and 157 (52.7%) initial TEE requests were inappropriate. When TEE was used as a supplemental test, 138 (61.9%) were technically appropriate and 122 (54.7%) clinically appropriate. Cardiologists submitted more appropriate requests (65.8%) than non-cardiologists. Among appropriate requests, IE was confirmed in 15.3% of cases.

Most US requests for suspected IE were inappropriate, particularly those made by non-cardiologists, highlighting the need for improved adherence to imaging guidelines, with potential benefits for patient care and resource management.