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Despite significant advances in understanding and outcomes in various domains of cardiology, the prognosis of infective endocarditis (IE) remains dismal. One of the main reasons may rely on an even more intricate diagnosis since epidemiology has shifted towards an aggressive infection, typically in older patients with the involvement of prosthetic valves and cardiovascular implantable electronic devices with earlier clinical presentation. In this novel setting, it is critical to avoid a delay in diagnosis that may delay subsequent adequate treatment, further complications, and ultimately poor clinical outcomes. Accordingly, based on the available data, we will examine the proper use of first-line echocardiography representing the first-line imaging method in patients with clinical suspicion of IE. We will focus on the following three crucial questions: (1) What is the threshold to start the echocardiographic diagnostic workup in stable patients? (2) Has infective endocarditis become a time-dependent diagnosis, even in stable patients? (3) What is the appropriate use of echocardiography in unstable patients? Finally, we propose a new mindset to improve the echocardiographic diagnostic workflow.

The modern conceptual revolution in managing patients with stable coronary artery disease (CAD), based on improvement in preventive and pharmacological therapy, advocates coronary artery revascularization only for smaller group of patients with refractory angina, poor left ventricular systolic function, or high-risk coronary anatomy. Therefore, our conventional wisdom about stress testing must be questioned within this new and revolutionary paradigm. Exercise stress echocardiography (ESE) is still a well-known technique for assessing known or suspected stable CAD, it is safe, accessible, and well-tolerated, and there is an widespread evidence base. ESE has been remarkably resilient throughout years of innovation in noninvasive cardiology. Its value is not to be determined over the short portion of diagnostic accuracy but mainly through its prognostic value evident in a wide range of patient subsets. It is coming very close to the modern profile of a leading test that should include, in addition to an essential accettable diagnostic and prognostic accuracy, qualities of low cost, no radiation exposure, and minor environmental traces. In this review, we will discuss advantages, diagnostic accuracy, prognostic value in general and special populations, cost-effectiveness, and changes in referral patterns of ESE in the modern era.