Utility of Transthoracic Echocardiography in Diagnostic Evaluation of Ischemic Stroke

Objective: Transthoracic echocardiography (TTE) is routinely performed as part of standard acute ischemic stroke (AIS) workup. However, the overall yield of TTE is unclear and many patients may undergo unnecessary investigations. This study aims to investigate the utility of TTE as part of AIS workup. Methods: We collected data on consecutive patients with AIS who were admitted to our institution between 07/01/2016 and 09/30/2017. Patients were included based on neuroimaging-documented AIS, age >18 and neuroimaging studies. Primary endpoint was the proportion of cases in which TTE yielded relevant finding, defined as Atrial Septa Defect or Patent Foramen Ovale, left atrial enlargement, left ventricular thrombus or ejection fraction of <35%. Secondary endpoint was the proportion of patients who had a TTE-drive change in management. Results: Among 548 AIS patients (median age 71 [59-81] years, 50% female), 482 (87%) underwent TTE. Clinically relevant findings were observed in 183 (38%) patients, leading to additional workup in 41 (8.5%). Further workup was associated with younger median age (58 [50-65] vs. 72 [62-81], p < 0.0001, and was less likely in suspected large vessel etiology (p = 0.02). Abnormal TTE lead to treatment change in 24 (5%) patients; 22/24 were started on anticoagulation. TTE results were less likely to influence treatment changes in older patients (71 [60-80] vs. 58 [49-69] years, p = 0.02) with known atrial fibrillation (p = 0.01). Conclusion: Our findings suggest that despite widespread use, the overall yield of TTE in AIS is low. Stratifying patients according to their likelihood of benefitting from it will be important toward better resource utilization.