Since the advent of two dimensional transthoracic echocardiography (TTE) in the 1970s and high frequency transoesophageal echocardiography (TOE) imaging in the 1980s, echocardiography has become a standard diagnostic tool in patients with suspected infective endocarditis (IE). It is now well established that echocardiography is a technology of choice for the diagnosis of IE,¹ and that echocardiography can detect cardiac involvement in a significant proportion of patients with clinically occult IE.^2,3 Because IE is a lethal infection that can be difficult to diagnose clinically, clinicians who care for patients at risk for IE often have a low threshold for employing echocardiography. This clinical practice has several implications. While echocardiography can often provide a rapid diagnosis, its optimal use is predicated on the appropriate pre-test probability of disease.^4,5 By contrast, echocardiography is increasingly overused in clinical scenarios with a low (< 2–3%) pre-test probability of disease, where its diagnostic utility diminishes.^6,7 …