Acute ischaemic stroke or transient ischaemic attack and the need for inpatient echocardiography
Bijoy K Menon1, Jonathan I Coulter2, Simerpreet Bal2
1Departments of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada Departments of Radiology, University of Calgary, Calgary, Alberta, Canada Community Health Sciences, University of Calgary, Calgary, Alberta, Canada Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.
Insights
Echocardiography in stroke patients revealed clinically relevant findings in 7.6%, significantly guiding medical management. A new risk score aids in predicting these findings for better stroke care.
Area of Science:
- Cardiology
- Neurology
- Medical Imaging
Background:
- In-hospital stroke and transient ischaemic attack (TIA) necessitate accurate diagnostic tools.
- Echocardiography, including transthoracic (TTE) and transoesophageal (TOE) methods, is used to identify potential cardiac sources of embolism.
- Determining the diagnostic yield and impact on management is crucial for optimizing its use.
Purpose of the Study:
- To assess the diagnostic yield of echocardiography in patients with in-hospital stroke or TIA.
- To evaluate the utility of echocardiography in changing medical management for these patients.
- To develop a risk score to guide the appropriate use of echocardiography in this population.
Main Methods:
- A retrospective chart review of 370 patients who underwent TTE or TOE between January 2009 and June 2010.
- Identification of 'potential clinically relevant findings' on echocardiograms.
- Multivariable logistic regression analysis to identify predictors and derive a risk score.
Main Results:
- Echocardiography revealed potential clinically relevant findings in 7.6% of patients.
- Medical management was altered in 6.2% of TTE cases and 11.1% of TOE cases.
- Male sex, abnormal admission ECG, and embolic pattern imaging were independent predictors (c-statistic 0.69).
Conclusions:
- Echocardiography has a low yield for findings but a high impact on management in stroke/TIA patients.
- The derived risk score, incorporating sex, ECG, and imaging, shows modest ability to predict positive findings.
- This score may assist in guiding echocardiography use for selected patients.
Objectives:
To determine the diagnostic yield of echocardiography and its utility in changing medical management; and to derive a risk score to guide its use in patients with in-hospital stroke or transient ischaemic attack (TIA).
Methods:
We carried out a retrospective chart review from January 2009 to June 2010 of patients with acute ischaemic stroke or TIA who had undergone transthoracic echocardiography (TTE) or transoesophageal echocardiography (TOE). Clinical and imaging findings at baseline were noted and 'potential clinically relevant findings' identified on TTE and TOE. A multivariable logistic regression was used to identify predictors of potential clinically relevant findings on TTE or TOE and derive a risk score.
Results:
Of 370 patients, 307 (83.0%) had TTE and 63 (17.0%) had additional TOE. Potential clinically relevant findings on echocardiography were noted in 28 (7.6%) patients. Change in medical management was noted in 19/307 (6.2%) patients on TTE and in 7/63 (11.1%) patients on TOE. Male sex (OR 3.05, 95% CI 1.19 to 7.84; p=0.021), abnormal admission ECG (OR 4.39, 95% CI 1.79 to 10.79; p=0.001), and embolic pattern imaging at baseline (OR 2.38, 95% CI 1.05 to 5.40; p=0.038) were independent predictors of findings on TTE or TOE. A risk score including these three variables had modest discrimination (c-statistic 0.69, 95% CI 0.59 to 0.80).
Conclusions:
Echocardiography detected potential clinically relevant findings in a minority of patients (7.6%), but these findings changed medical management 90.5% of the time. A risk score using sex, ECG abnormality, and embolic pattern imaging at baseline could help predict which patients are more likely to have these echo findings.
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