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Overuse of Transthoracic Echocardiography in the Diagnosis of Native Valve Endocarditis
Janaki C. Kuruppu, MD;
Mary Corretti, MD;
Philip Mackowiak, MD;
Mary-Claire Roghmann, MD, MS
Arch Intern Med. 2002;162:1715-1720.
Background Infective endocarditis (IE) is a diagnostic challenge due to its variable
presentation and nonspecific clinical findings. The use of transthoracic echocardiography
(TTE) has greatly improved the ability to diagnose IE early, and therefore
reduce high mortality and morbidity rates. However, reliance on TTE to exclude
IE may lead to overuse of this technology in patients with a low pretest probability
of IE.
Methods Prospective observational study of all patients referred for TTE to
diagnose IE. Clinical factors were used to determine likelihood of IE based
on the Von Reyn criteria, and the resulting diagnostic probabilities were
correlated with abnormal TTE findings as well as duration of antibiotic therapy.
Results One hundred eleven TTEs performed on 98 patients were included in the
analysis. Over 70% of TTEs were obtained in patients in whom the diagnosis
of IE was rejected by Von Reyn criteria. Therapeutic
management (prolonged antibiotic administration) was associated significantly
with Von Reyn categorization, and not significantly affected by TTE results.
Conclusions Most TTEs are obtained in patients with a low pretest probability of
IE and do not contribute to therapeutic decision making. We propose a diagnostic
algorithm to direct the use of TTE to patients with intermediate or high pretest
probability of IE.
From the Vaccine Research Center, National Institutes of Health, Bethesda,
Md (Dr Kuruppu); and the Department of Medicine, University of Maryland (Drs
Corretti and Mackowiak), the Medical Care Clinical Center, Veterans Administration
Maryland Health Care System (Drs Mackowiak and Roghmann), and the Department
of Epidemiology and Preventive Medicine, University of Maryland (Dr Roghmann),
Baltimore.
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