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[Search for emboligenic heart disease in case of ischemic cerebral accidents]
D Thomas1, G Lascault, G Drobinski
1Service de cardiologie, hôpital de la Salpêtrière, Paris.
Insights
Identifying cardiac sources of systemic embolism after ischemic stroke is crucial. A selective diagnostic approach, prioritizing patient history and initial tests, is recommended over indiscriminate cardiac investigations.
Area of Science:
- Cardiology
- Neurology
- Diagnostic Imaging
Background:
- Systemic embolism from cardiac sources is a significant cause of ischemic stroke.
- Non-invasive cardiac investigations like echocardiography are frequently used.
- Overutilization of these tests is driven by their precision and the frequency of cardiac embolism.
Purpose of the Study:
- To evaluate the necessity of a selective diagnostic approach for identifying cardiac sources of embolism in patients with cerebral ischemic events.
- To differentiate between highly embolic cardiac conditions and those with doubtful embolic potential.
Main Methods:
- Review of clinical situations and diagnostic work-up for cardiac embolism.
- Emphasis on initial diagnostic steps: patient history, clinical examination, ECG, and chest X-ray.
- Categorization of cardiac abnormalities based on embolic potential.
Main Results:
- A selective approach is favored due to the large number of potential patients and limited resources.
- Cardiac abnormalities with high embolic potential (e.g., mitral stenosis, endocarditis) require focused echocardiography for management.
- Cardiac abnormalities with low embolic potential (e.g., mitral valve prolapse) are less informative for etiological diagnosis of cerebral embolism.
Conclusions:
- Careful clinical assessment and initial investigations are key to diagnosing cardiac sources of embolism.
- Echocardiography is valuable for highly embolic conditions but less discriminative for those with doubtful embolic potential.
- A selective diagnostic strategy optimizes resource utilization and patient management.
Abstract:
The demonstration of a cardiac source of systemic embolism in patients who have suffered a cerebral ischemic event may have important therapeutic implications. This explains the large demand for echocardiography and Holter monitoring in these patients. The frequency of cerebral embolism of cardiac origin, the simplification of the diagnostic approach by non-invasive investigations and the precision of ultrasound techniques explains the tendency towards the indiscriminate generalisation of this attitude. However, the large number of potential patients for investigation, the limited facilities of investigation and the incertitude over the responsibility of certain cardiac abnormalities with respect to the context and age, are arguments in favour of a more selective investigative approach. The keystone of diagnosis is careful history taking and clinical examination with interpretation of the ECG and chest X-ray. Three clinical situations may then be identified: 1) A cardiac abnormality known to be highly embolic is diagnosed from the outset (e.g. mitral stenosis, valve prosthesis, endocarditis, myocardial infarction). The diagnostic work-up is no longer etiological: echocardiography may show intracardiac thrombi or a valvular vegetation, reinforcing the causal relationship, but the complementary investigations are mainly useful for evaluation the cardiac disease and for deciding on curative or preventive therapy. 2) A cardiac abnormality is diagnosed but its responsibility is doubtful due to its high prevalence and low embolic potential. This is the case of patients with mitral valve prolapse, mitral annular calcification, calcific aortic stenosis and VVI pacing. Complementary investigations are not discriminative for the etiological diagnosis of the cerebral embolism.(ABSTRACT TRUNCATED AT 250 WORDS)