Related Experiment Video
Updated: Jul 28, 2025
Prehospital Thrombolysis: A Manual from Berlin
Published on: November 26, 2013
Extent of routine diagnostic cardiac work-up at certified German stroke units participating in the prospective
Manuel C Olma1,2, Serdar Tütüncü1,3, Ulrike Grittner4
1Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.
Insights
Cardiac diagnostic work-up for stroke patients varied significantly across German stroke centers. Echocardiography and Holter-ECG use differed by hospital type, impacting atrial fibrillation detection and stroke care standardization.
Area of Science:
- Cardiology
- Neurology
- Public Health
Background:
- Cardio-embolism accounts for 25% of ischemic strokes, often linked to atrial fibrillation (AF).
- Limited data exists on the standardization of cardiac diagnostic work-up in German stroke units.
Purpose of the Study:
- To analyze the extent and standardization of routine cardiac diagnostic work-up in certified stroke units in Germany.
- To compare diagnostic practices across different levels of stroke centers: university-based comprehensive stroke centers (UCSC), non-university comprehensive stroke centers (nUCSC), and primary stroke centers (PCS).
Main Methods:
- The MonDAFIS study included 3431 non-AF patients with acute ischemic stroke or TIA across 38 German stroke units.
- Routine diagnostic work-up, including 24-h Holter-ECG and echocardiography (TEE/TTE), was analyzed, excluding study-specific monitoring.
- Multivariable mixed regression analyses compared diagnostic rates and stroke-unit stay duration across UCSC, nUCSC, and PCS.
Main Results:
- Stroke-unit stay was longer for severe strokes and ischemic strokes compared to TIA.
- 24-h Holter-ECG monitoring varied significantly: 47% in UCSC, 71% in nUCSC, and 84% in PCS.
- Echocardiography rates also varied, with PCS performing it most frequently (90.3%), while AF detection was lower in UCSC and nUCSC compared to PCS.
Conclusions:
- Routine echocardiography and Holter-ECG use in stroke units show considerable variation based on certification grade and university affiliation.
- These findings highlight a lack of standardization in cardiac diagnostic work-up for stroke patients in Germany.
- Further research is needed to optimize diagnostic protocols and improve stroke care consistency.
Background:
About 25% of all ischaemic strokes are related to cardio-embolism, most often due to atrial fibrillation (AF). Little is known about the extent and standardization of routine cardiac diagnostic work-up at certified stroke-units in Germany.
Methods:
The MonDAFIS study included non-AF patients with acute ischaemic stroke or transient ischaemic attack (TIA) at 38 certified stroke-units in Germany. Here, we analysed routine diagnostic work-up and disregarded study-related Holter-ECG monitoring. We compared duration of stroke-unit stay, number of 24-h Holter-ECGs, and echocardiography performed between university-based comprehensive stroke centres (UCSC, 12 hospitals, 1606 patients), non university-based comprehensive stroke centres (nUCSC, 14 hospitals, 892 patients), and primary stroke centres at non-university hospitals (PCS, 12 hospitals, 933 patients) using multivariable mixed regression analyses. Detection of a first AF episode in-hospital was also compared between hospitals of different stroke-unit levels.
Results:
In 3431 study patients (mean age 66.2 years, 39.5% female, median NIHSS = 2 on admission), median duration of the stroke-unit stay was 72 h (IQR 42-86). Stroke-unit stay was longer (categorised ≤ 24/ > 24- ≤ 72/ > 72 h) for patients with severe stroke (NIHSS score ≥ 5/ < 5: OR = 1.6, 95%CI 1.3-2.0) and for patients with ischaemic stroke vs. TIA (OR = 1.7, 95%CI 1.4-2.1). Overall, 2149/3396 (63.3%) patients underwent at least one additional 24-h Holter-ECG (median 1 [IQR 0-1], range 0-7). Holter-ECG rate was 47% in UCSC, 71% in nUCSC, and 84% in PCS. Compared to PCS, AF was less often detected in-hospital in UCSC (OR = 0.65, 95%CI 0.45-0.93) and nUCSC (OR = 0.69, 95%CI 0.46-1.04). Transoesophageal echocardiography (TEE) only was performed in 513/3391 (15.1%) study patients, transthoracic echocardiography (TTE) only in 1228/3391 (36.2%), and TEE combined with TTE in 1020/3391 (30.1%) patients. Patients younger than 60 years (vs. ≥ 60 years) underwent TEE more often than those older than 60 years (OR = 3.44, 95%CI 2.67-4.42). TEE (IQR 34-65%) and TTE rate (IQR 40-85%) varied substantially among study centres. Echocardiography rate (TTE and/or TEE) was 74.0% in UCSC, 85.4% in nUCSC, and 90.3% in PSC, respectively.
Conclusions:
In the MonDAFIS study, the routine use of echocardiography and Holter-ECG monitoring varied in participating stroke centres and at stroke-unit level, if grouped according to stroke-unit certification grade and hospitals´ university status. Trial registration Clinical Trials, NCT02204267. Registered 30 July 2014, https://clinicaltrials.gov/ct2/show/NCT02204267 .
Related Concept Videos
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:30Dysrhythmias V: Evaluating Dysrhythmias
01:22Rheumatic Heart Disease II: Clinical Manifestations and Diagnostic Studies
01:21Imaging Studies for Cardiovascular System IV: CMRI
01:28Imaging Studies for Cardiovascular System V: CT
01:17Imaging Studies for Cardiovascular System I:Echocardiography
Indications: Echocardiography is utilized to diagnose heart failure, valve disorders, and myocardial infarction. It also assesses cardiac structures' size, shape, and motion,...