To the Editor.
—Among the recently published changes in the updated recommendations by the AHA for prevention of infective endocarditis, much discussion was devoted to its application for patients with mitral valve prolapse. Unfortunately, after reading the entire article, I was afraid that many readers would probably be left with a considerable amount of uncertainty and ambiguity.The old teaching of "no murmur, no prophylaxis" has been challenged, because murmurs of mitral regurgitation in patients with mitral valve prolapse can come and go. Furthermore, unless the clinician performs dynamic auscultation, many patients with mitral valve prolapse may not reveal a late systolic murmur at a given time. Echocardiography has not resulted in changes in antibiotic prophylaxis management and has been associated with significant expense.2Infective endocarditis complicating mitral valve prolapse causes considerable cumulative morbidity and incremental health care costs, but antibiotic prophylaxis against infective endocarditis is highly cost-effective.3 If "men older