Limitations of transoesophageal echocardiogram in acute ischaemic stroke
Zachary P Rosol1, Kathleen F Kopecky1, Bailey R Minehart1
1Department of Cardiology, Baylor University Medical Center at Dallas, Dallas, Texas, USA.
Insights
Transoesophageal echocardiography (TOE) rarely alters management for ischaemic stroke patients. This study supports guidelines recommending against routine echocardiography for cardioembolic stroke evaluation.
Area of Science:
- Cardiology
- Neurology
- Medical Imaging
Background:
- The utility of transoesophageal echocardiography (TOE) in determining ischaemic stroke causes is debated.
- Guidelines suggest echocardiography use only when findings alter patient management.
- This study evaluates the impact of TOE findings on management decisions in ischaemic stroke cases.
Purpose of the Study:
- To determine the rate at which transoesophageal echocardiography findings changed management in patients with confirmed ischaemic stroke.
- To assess the adherence to American Heart Association/American Stroke Association (AHA/ASA) guidelines regarding echocardiography use.
Main Methods:
- Retrospective analysis of 150 patients undergoing TOE for confirmed ischaemic stroke between April 2015 and February 2017.
- Defined "change in management" as initiation of anticoagulation, antibiotic therapy, or patent foramen ovale closure directly due to TOE findings.
Main Results:
- Out of 185 patients, 19 (10.3%) had a management change, but only 7 (3.8%) were directly attributed to TOE findings.
- The majority of management changes (12 patients) resulted from routine workup, primarily detecting atrial fibrillation.
Conclusions:
- Transoesophageal echocardiography may be overused in the workup of ischaemic stroke.
- Findings support the 2018 AHA/ASA guidelines advising against routine echocardiography for cardioembolic stroke evaluation.
Objective:
The role of transoesophageal echocardiography (TOE) in identifying ischaemic stroke aetiology is debated. In 2018, the American Heart Association/American Stroke Association (AHA/ASA) issued class IIa recommendation for echocardiography, with the qualifying statement of use in cases where it will alter management. Hence, we sought to determine the rate at which TOE findings altered management in cases of confirmed ischaemic stroke.
Methods:
We retrospectively analysed TOE cases with confirmed ischaemic stroke at our centre between April 2015 and February 2017. We defined a change in management as the initiation of anticoagulation therapy, antibiotic therapy or patent foramen ovale closure as a direct result of TOE findings.
Results:
There were 185 patients included in this analysis; 19 (10%) experienced a change in management. However, only 7 of the 19 (4% of all subjects) experienced a change in management due to TOE findings. The remaining 12 were initiated on oral antigoagulation as a result of discoveries during routine workup, mainly atrial fibrillation on telemetry monitoring.
Conclusions:
This work suggests an overuse of TOE and provides support for the 2018 AHA/ASA stroke guidelines, which recommend against the routine use of echocardiography in the work up of cerebrovascular accident due to a cardioembolic source.
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