Utility of Transthoracic Echocardiography in Diagnostic Evaluation of Ischemic Stroke

Harris, Jennifer; Yoon, Jason T.; Salem, Mohamed M; Selim, Magdy; Kumar, Sandeep; Lioutas, Vasileios

doi:10.3389/fneur.2020.00103

Cited by 9 publications

(9 citation statements)

References 29 publications

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“…In patients with infective endocarditis, only 10% of the findings in FDG PET/CT of the heart led to changes in treatment [ 266 ]. Routine transthoracic echocardiography in acute ischemic stroke patients had relevant findings in 38% of patients, however only 8.5% of patients had additional work-up [ 267 ]. Elective coronary angiography investigating coronary heart disease had relevant findings in 40% of patients in one study [ 268 ].…”

Section: Resultsmentioning

confidence: 99%

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

et al. 2022

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Background Inappropriate and wasteful use of health care resources is a common problem, constituting 10–34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging—in which the diagnostic test confers little to no clinical benefit—is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children. Methods A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included. Results A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations. Conclusions A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally. Systematic review registration: PROSPERO: CRD42020208072.

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Section: Resultsmentioning

confidence: 99%

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

et al. 2022

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“…Harris et al 4 found that in patients with known AF, TTE results were less likely to influence treatment changes (adjusted odds ratio, 0.12; 95% CI, 0.006–0.66). Douen et al 24 reported that in 31 patients with newly diagnosed or known AF, TTE identified 1 left ventricular thrombus and moderate to severe left ventricular dysfunction in 2 additional patients with a history of myocardial infarction, suggesting that TTE does not provide relevant results in this cohort.…”

Section: Discussionmentioning

confidence: 99%

Yield of Echocardiography in Ischemic Stroke and Patients With Transient Ischemic Attack With Established Indications for Long‐Term Direct Oral Anticoagulant Therapy: A Cross‐Sectional Diagnostic Cohort Study

Meinel

Brignoli

Kielkopf

et al. 2022

JAHA

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Background We aimed to determine the diagnostic yield of transthoracic (TTE) and transesophageal echocardiography (TEE) in patients with ischemic stroke and transient ischemic attack with established indications for direct oral anticoagulants before the index event. Methods and Results This was a retrospective cohort study of consecutive patients with preceding established indications for long‐term therapeutic direct oral anticoagulants presenting to a single comprehensive stroke center with ischemic stroke or transient ischemic attack. Choice of echocardiography modality was based on expert recommendations. The primary outcome was a composite of prespecified management‐relevant high‐risk findings adjudicated by an expert panel, based on TTE and TEE reports according to evidence‐based recommendations. Explorative analyses were performed to identify biomarkers associated with the primary outcome. Of 424 patients included (median [interquartile range] age, 78 [70–84] years; 175 [41%] women; National Institutes of Health Stroke Scale, 4 [1–12]; 67% atrial fibrillation), 292 (69%) underwent echocardiography, while 132 (31%) did not. Modality was TTE in 191 (45%) and TEE in 101 (24%). Median time from index event to echocardiography was 2 (1–3) days. TTE identified 26 of 191 (14%) patients with 35 management‐relevant pathologies. TEE identified 16 of 101(16%) patients with 20 management‐relevant pathologies. Most management‐relevant findings represented indicated coronary artery disease and valvular pathologies. In a further 3 of 191 (2%) patients with TTE and 4 of 101 (4%) patients with TEE, other relevant findings were identified. Variables associated with management‐relevant high‐risk pathologies included more severe stroke, diabetes, and laboratory biomarkers (NT‐proBNP [N‐terminal pro‐B‐type natriuretic peptide], C‐reactive protein, d ‐dimer, and troponin levels). Conclusions In patients with established indications for long‐term direct oral anticoagulant therapy and stroke who received echocardiography, both TTE and TEE identified a relevant and similar proportion of management‐relevant high‐risk pathologies and predictive biomarkers could help to guide diagnostic workup in such patients.

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“…Thus, a thorough investigation of the patient is important for the proper characterization and management of ischemic stroke. Emerging evidence suggests that atrial enlargement may be a biomarker of AF-independent underlying thrombogenic atrial heart disease with an independent risk of indeterminate or recurrent cardioembolic stroke (17).…”

Section: Discussionmentioning

confidence: 99%

“…The American Heart Association and American Stroke Association (AHA/ASA) guidelines recommend echocardiography for evaluating a patient with ischemic stroke only in selected cases (class IIa/class IIb). A recent study published by Harris et al aimed to investigate the utility of transthoracic echocardiography (TTE) as a part of an acute ischemic stroke workup and revealed that the overall yield of TTE in acute ischemic stroke was low (17). Conversely, TTE has been performed as part of the assessment of stroke patients in recent years.…”

Section: Introductionmentioning

confidence: 99%

The Role of Transthoracic Echocardiography in the Evaluation of Patients With Ischemic Stroke

Teodoro

Silva

Módolo

et al. 2021

Front. Cardiovasc. Med.

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Background: Ischemic stroke can be classified into five etiological types, according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, and its adequate investigation and characterization can aid in its clinical management and in preventing new events. Transthoracic echocardiography (TTE) plays a key role in investigating its etiology; approximately one-third of the patients remain without an adequate definition of the etiology or are classified as the undetermined TOAST type.Objectives: To evaluate if the percentage of patients with indeterminate etiology according to the TOAST classification decreased after transthoracic echocardiography, to determine whether or not the prognosis after ischemic stroke is worse among patients classified as the undetermined TOAST type, and to verify the predictive capacity of echocardiography on the prognosis after ischemic stroke.Methods: In this retrospective cohort study, clinical, neurological, and echocardiographic examinations were conducted when the patient was hospitalized for stroke. In-hospital mortality and functional capacity were evaluated at hospital discharge and 90 days thereafter. Multiple linear regression and multiple logistic regression models were adjusted for confounding factors. The level of significance was 5%.Results: A total of 1,100 patients (men = 606; 55.09%), with a mean age of 68.1 ± 13.3 years, were included in this study. Using TTE, 977 patients (88.82%) were evaluated and 448 patients (40.7%) were classified as the undetermined TOAST type. The patients who underwent TTE were 3.1 times less likely to classified as the undetermined TOAST type (OR = 0.32; p < 0.001). Echocardiography during hospitalization was a protective factor against poor prognosis, and reduced the odds of in-hospital death by 11.1 times (OR: 0.090; p < 0.001). However, the presence of the undetermined TOAST classification elevated the chance of mortality during hospitalization by 2.0 times (OR: 2.00; p = 0.013).Conclusions: Echocardiography during hospitalization for ischemic stroke reduces the chances of an undetermined TOAST classification and the risk of in-hospital mortality. However, being classified as the undetermined TOAST type increases the chance of mortality during hospitalization, suggesting that evaluating patients using echocardiography during hospitalization for acute ischemic stroke is important.

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Utility of Transthoracic Echocardiography in Diagnostic Evaluation of Ischemic Stroke

Cited by 9 publications

References 29 publications

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

Yield of Echocardiography in Ischemic Stroke and Patients With Transient Ischemic Attack With Established Indications for Long‐Term Direct Oral Anticoagulant Therapy: A Cross‐Sectional Diagnostic Cohort Study

The Role of Transthoracic Echocardiography in the Evaluation of Patients With Ischemic Stroke

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