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Sheldon M. Singh, MD; Campbell D. Joyner, MD; David A. Alter, MD, PhD

Arch Intern Med. 2006;166:549-553.

Background  Guidelines advocate for antimicrobial prophylaxis for prevention of bacterial endocarditis. Our objective was to explore physicians' perspectives regarding the importance of echocardiography in the evaluation and management of endocarditis prophylaxis.

Methods  A total of 260 cardiologists and 300 family physicians practicing in Ontario, Canada, were surveyed. Our main outcome measures were physician ratings of the importance of a murmur, echocardiogram findings, echocardiogram comments, comorbid conditions, guidelines, patient insistence, and medicolegal concerns on the decision to recommend prophylaxis, as well as the degree of echocardiographically detected mitral valve abnormality required prior to recommending prophylaxis.

Results  The survey response rate was 62%. Echocardiographic findings were rated by 81% of physicians as the most important factor influencing the decision to provide prophylaxis. Conversely, only 27% of physicians placed similar importance on clinical findings. Family physicians relied more heavily on echocardiographic than on clinical findings when supporting endocarditis prophylaxis recommendations. On average, prophylaxis was recommended for moderate to severe regurgitation in a normal valve and mild regurgitation in a mildly abnormal structural mitral valve. Physicians who reported greater reliance on echocardiographic findings advocated for prophylaxis at lower echocardiographic thresholds than did those who reported greater reliance on murmur detection for endocarditis prophylaxis decisions.

Conclusions  Physicians strongly support the use of echocardiography in endocarditis prophylaxis decision making. However, the importance of echocardiography relative to other factors varies across physician specialties. Further studies must evaluate the role of echocardiography in the assessment and management of antimicrobial endocarditis prophylaxis to assist in the development of clear clinical guidelines.

Author Affiliations: Department of Medicine, University of Toronto (Drs Singh, Joyner, and Alter); Division of Cardiology, Schulich Heart Centre, Sunnybrook and Women's College Health Sciences Centre (Drs Joyner and Alter); and The Institute for Clinical Evaluative Science (Dr Alter); Toronto, Ontario.

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