Secondary rheumatic heart disease prophylaxis is required even after valve replacement. Clinical or echocardiographic evidence. VHD indicates valvular heart disease. Adapted from Gerber et al.1 CLINICAL STATEMENTS AND GUIDELINES Synopsis With the absence of RCTs addressing the efficacy of anti- biotic prophylaxis for prevention of IE1,12 14 and given un- certainty about which patient populations are at highest risk, these recommendations are based on pathophysio- logical considerations, limited data, and clinical expertise. A prospective study demonstrated that prophylactic anti- biotics given to patients for what is typically considered a high-risk dental procedure reduced but did not eliminate the incidence of bacteremia.2 A 2013 Cochrane Data- base systematic review of antibiotic prophylaxis for the prevention of IE in dentistry concluded that there is no evidence to determine whether antibiotic prophylaxis is effective or ineffective, highlighting the need for further study of this long-standing clinical dilemma.1 Epidemio- logical data conflict with regard to changes in the in- cidence of IE after adoption of more limited antibiotic The consensus of the writing committee is that antibiotic prophylaxis is reasonable for the subset of patients at highest risk of developing IE and at high risk of experiencing adverse outcomes from IE. There is no evidence for IE prophylaxis in gastrointestinal procedures or genitourinary procedures, in the absence of known active infection. Recommendation-Specific Supportive Text 1. 