Approximately 33% of patients with schizophrenia are treatment-refractory, yet clozapine remains underused, even though it is the most effective treatment. One barrier is routine echocardiography, which in Australia is performed before clozapine initiation, six months afterwards and then annually. Elsewhere, such as in New Zealand, routine echocardiography is generally restricted to the initiation of therapy, while in the UK, it is not routine practice at all. Importantly, the latest guidelines from The Royal Australian and New Zealand College of Psychiatrists (RANZCP) suggest routine annual echocardiography adds little to the detection of cardiomyopathy. We therefore review the evidence for routine echocardiography. This is particularly relevant to general practitioners (GPs) as they become more involved in managing patients on clozapine through shared-care arrangements.