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Transesophageal echocardiography in patients with cryptogenic ischemic stroke: a systematic review
Emer R McGrath1, Jeremy S Paikin2, Bahareh Motlagh2
1HRB Clinical Research Facility, National University of Ireland Galway, Galway, Ireland; Department of Neurology, Massachusetts General Hospital, Boston MA.
Insights
Routine transesophageal echocardiography (TEE) in cryptogenic ischemic stroke (IS) patients reveals cardiac findings but with significant variation. Its routine utility remains uncertain despite prompting anticoagulation in some cases.
Area of Science:
- Cardiology
- Neurology
- Medical Imaging
Background:
- The clinical value of routine transesophageal echocardiography (TEE) for unexplained ischemic stroke (IS) is debated.
- This systematic review assesses the frequency of new cardiac findings in cryptogenic IS patients undergoing TEE.
Purpose of the Study:
- To determine the prevalence of new cardiac findings detected by TEE in patients with cryptogenic IS.
- To evaluate the proportion of patients initiated on oral anticoagulation following TEE findings.
Main Methods:
- Systematic review and meta-analysis of cohort studies involving patients with cryptogenic IS.
- Patients were stratified into two age groups: <55 years (Group A) and ≥55 years (Group B).
- Outcomes included the proportion of new TEE-detected cardiac findings and subsequent anticoagulation initiation.
Main Results:
- Twenty-seven studies (n=5,653) showed significant heterogeneity in prevalence rates for findings like patent foramen ovale, atrial septal aneurysm, left atrial thrombus, spontaneous echo contrast, and aortic atheroma.
- Prevalence varied widely between age groups and studies, with inconsistent definitions for common findings.
- Anticoagulant therapy was initiated in 0-30.7% of patients post-TEE, often without clear guideline-based indications.
Conclusions:
- Routine TEE identifies cardiac findings in a substantial proportion of cryptogenic IS patients.
- Marked interstudy variation in definitions and prevalence of findings complicates interpretation.
- While TEE can prompt anticoagulation, its routine indication in cryptogenic IS requires further evidence due to unclear benefits and guideline adherence.
Background:
The clinical utility of routine transesophageal echocardiography (TEE) for patients with unexplained ischemic stroke is controversial. We performed a systematic review to determine the frequency of detection of new cardiac findings in patients with cryptogenic ischemic stroke (IS) undergoing transesophageal echocardiography (TEE).
Methods:
Systematic review and meta-analysis of cohort studies of consecutive patients with "cryptogenic" IS undergoing TEE after routine etiologic workup. Patients were categorized into 2 groups: A (< 55 years) and B (≥ 55 years). Outcomes included proportion of patients with new TEE-detected cardiac findings and proportion of patients commenced on oral anticoagulation after TEE.
Results:
Twenty-seven studies were included (n = 5,653). We identified significant heterogeneity among studies and report a range of prevalence rates and I2 statistic as our primary analysis. Prevalence of individual cardiac findings on TEE varied significantly among studies; patent foramen ovale (A: 12.0%-57.8%, I2 = 89.9%; B: 3.9%-43.5%, I2 = 86.7%), atrial septal aneurysm (A: 0-48.9%, I2 = 91.9%; B: 3.5%-25.0%, I2 = 84.5%), left atrial thrombus (A: 0-10.9%, I2 = 61.1%; B: 0-21.2%, I2 = 91.7%), spontaneous echo contrast (A: 0-11.9%, I2 = 57.2%; B: 0-21.3%, I2 = 89.8%), and aortic atheroma (A: 0-9.6%, I2 = 53.8%; B: 2.8%-44.4%, I2 = 89.7%). Definitions of common findings were not provided for many studies. Five studies (n = 591) reported on the proportion of patients who were commenced on anticoagulant therapy after TEE (range 0-30.7%).
Conclusions:
Routine TEE in patients with cryptogenic IS identifies cardiac findings in a large proportion. However, there is marked interstudy variation in the definition and prevalence of common findings. Transesophageal echocardiography-detected findings prompted the introduction of anticoagulant therapy in up to one-third of patients. However, these were mostly not for established guideline-based indications based on randomized controlled trial evidence. It is unclear if routine use of TEE in patients with cryptogenic IS is indicated.
