Health Services

Abstract

S troke is the third leading cause of death in high-income countries, and accounts for substantial morbidity in those who survive. 1 Ischemic stroke is primarily due to a thrombotic or embolic event, and emboli frequently originate in the heart. 2 Transthoracic echocardiography can sometimes diagnose cardiac sources of embolism, such as atrial or ventricular thrombus, 3-5 and these generally require anticoagulation. Transthoracic echocardiography can also identify other causes of stroke that may require intervention, such as atrial abnormalities (e.g., patent foramen ovale, atrial myxoma) 6-8 or infective endocarditis. Transthoracic echocardiography is often recommended to plan secondary stroke management, but it is unclear how often this test provides clinically actionable findings. 4,9 Previous studies provide a range of conflicting estimates for how often transthoracic echocardiography might affect patient management because of changing opinions on what pathology is considered clinically relevant. 10,11 For example, dilated cardiomyopathy is no longer an indication for anticoagulation among patients with stroke. 12 Other findings previously considered to be incidental, such as patent foramen ovale, are now clinically actionable among patients with cryptogenic stroke. 6-8 Current stroke clinical practice guidelines do not reflect these nuanced data, making it challenging for physicians to know which patients should have transthoracic echocardiography after an ischemic stroke. 9,13,14 Furthermore, data that are both comprehensive and recent are lacking to further understanding of how often patients in routine care with stroke will have echocardiographic findings that are clinically actionable. Choosing Wisely 15 advocates against routine low-value care that is unlikely to improve patient care or is likely to cause harm. Transthoracic echocardiography is unlikely to cause direct patient harm but may cause indirect harm; for example, where incidental findings lead to invasive testing (i.e., transesophageal echocardiography) and expose patients to additional risks. Awaiting transthoracic echocardiography can also RESEARCH HEALTH SERVICES

Clinical Utility and Cost of Inpatient Transthoracic Echocardiography Following Acute Ischemic Stroke

“…Previous studies reported clinically relevant findings on TTE in 3-37% of stroke patients, though nearly all studies report rates below 20%. [1][2][3][4][5][6][7] This variability is most likely explained by evolving definitions of clinically relevant findings and subsequent management based on current practices. For example, we chose to exclude PFO or left atrial enlargement as they do not immediately change management.…”

“…23 A recent Canadian study reported that median length of hospital stay for stroke patients was 3 days longer for patients receiving echocardiography, suggesting that prolonging inpatient admission to expedite TTE is not unique to our center. 7 There is limited data regarding the cost-effectiveness of TTE in secondary stroke prevention. Two prior American studies used computer modeling to complete a costeffectiveness analysis of echocardiography after first ischemic stroke, and both found that TTE alone or in combination with other strategies was not cost-effective, though one found TEE to be cost-effective.…”

“…Previous studies report significant variability in the utility of TTE in this context, potentially owing to different definitions of clinically relevant findings. [1][2][3][4][5][6][7] Currently, there are no clear guidelines for the timing of cardiac investigations after ischemic stroke, particularly in relation to which tests should be performed prior to discharge from hospital. 8 Also, the cost-effectiveness of TTE after stroke is unclear, as it has only been reported in a limited number of studies using computer modeling, and none that used real patients.…”

Readjustment of antithrombotic therapy in stroke-patients owing to transesophageal echocardiography findings

“…However, the rate of TEE in the cohort in the present study was low, occurring in just 1 out of 10 stroke patients. In a multicenter cohort study of nearly 2.000 patients with ischemic stroke or TIA, 68% had an echocardiogram (most often a transthoracic), and the results were normal 86% of the time, whereas the 2 most common clinically actionable indings for secondary stroke prevention were cardiac thrombus and PFO [33]. The wide range of estimates for how often "clinically relevant" indings are detected on echocardiogram for patients with an ischemic stroke is partially related to changing criteria for what is considered clinically relevant, e.g., anticoagulation is no longer recommended in clinical practice guidelines for dilated cardiomyopathy [34].…”

İskemik inmede ekokardiyografi bulgularının inme şiddeti, hemorajik transformasyon ve kısa dönem prognoz ile ilişkisi

“…Transözofageal ekokardiyografi (TEE) kardiyoembolik inmede intrakardiyak ve sol atriyal trombüsü dışlamakta daha duyarlıdır. Ancak transtorasik ekokardiyografi (TTE) daha kolay ulaşılabilen ve uygulanabilen bir inceleme yöntemidir [5].…”