Routine transthoracic echocardiography in ischaemic stroke or transient ischaemic attack of undetermined cause:
Gerlinde van der Maten1,2, Matthijs F L Meijs3, Jorik R Timmer4
1Department of Neurology, Medisch Spectrum Twente, Enschede, The Netherlands.
Insights
Routine transthoracic echocardiography (TTE) rarely detects major cardiac sources of embolism (CSE) in stroke patients with undetermined causes. Most identified CSE cases had pre-existing ECG abnormalities, questioning the routine TTE
Area of Science:
- Cardiology
- Neurology
- Diagnostic Imaging
Background:
- Current guidelines recommend transthoracic echocardiography (TTE) for patients with ischemic stroke or transient ischemic attack (TIA) of undetermined origin.
- However, robust scientific evidence supporting routine TTE in this population is limited.
- This study investigates the prevalence of TTE-detected major cardiac sources of embolism (CSE) that could alter patient management.
Purpose of the Study:
- To determine the prevalence of major cardiac sources of embolism (CSE) detected by transthoracic echocardiography (TTE) in patients with ischemic stroke or transient ischemic attack (TIA) of undetermined cause.
- To assess whether TTE findings in this cohort lead to therapeutic changes.
- To evaluate the clinical utility of routine TTE in the diagnostic workup of cryptogenic stroke.
Main Methods:
- A prospective, observational, multicenter study involving 1084 patients across six Dutch hospitals.
- Patients underwent comprehensive diagnostic evaluation, including TTE, after initial workup on stroke units.
- The primary outcome was the proportion of patients with TTE-detected major CSE.
Main Results:
- Transthoracic echocardiography (TTE) detected major cardiac sources of embolism (CSE) in only 1.0% of patients (11 out of 1084).
- Of the patients with detected CSE, 90.9% (10 patients) also had significant electrocardiogram (ECG) abnormalities.
- These ECG abnormalities alone would have justified TTE assessment, suggesting limited additional value from routine TTE in these cases.
Conclusions:
- Routine transthoracic echocardiography (TTE) detects major cardiac sources of embolism (CSE) in a very small percentage (1.0%) of patients with ischemic stroke or transient ischemic attack (TIA) of undetermined cause.
- The majority of CSE findings in this study were associated with pre-existing major ECG abnormalities.
- These findings challenge the current guideline recommendation for routine TTE in this specific clinical scenario, suggesting a need for re-evaluation of its diagnostic yield.
Background:
Guidelines recommend routine transthoracic echocardiography (TTE) after ischaemic stroke or transient ischaemic attack of undetermined cause; yet, only limited scientific evidence exists. Therefore, we aimed to determine in these patients the prevalence of TTE-detected major cardiac sources of embolism (CSE), which are abnormalities leading to therapeutic changes.
Methods:
Six Dutch hospitals conducted a prospective observational study that enrolled patients with ischaemic stroke or transient ischaemic attack of undetermined cause. Patients underwent TTE after comprehensive diagnostic evaluation on stroke units, including blood chemistry, 12-lead electrocardiogram (ECG), ≥ 24 h continuous ECG monitoring, brain imaging and cervical artery imaging. Primary outcome measure was the proportion of patients with TTE-detected major CSE.
Results:
From March 2018 to October 2020, 1084 patients, aged 66.6 ± 12.5 years, were enrolled; 456 (42.1%) patients were female and 869 (80.2%) had ischaemic stroke. TTE detected major CSE in only 11 (1.0%) patients. Ten (90.9%) of these patients also had major ECG abnormalities (previous infarction, major repolarisation abnormalities, or previously unknown left bundle branch block) that would have warranted TTE assessment regardless of stroke evaluation. Such ECG abnormalities were present in 11.1% of the total study population. A single patient (0.1%) showed a major CSE despite having no ECG abnormality.
Conclusions:
This multicentre cross-sectional study in patients who-after workup on contemporary stroke units-were diagnosed with ischaemic stroke or transient ischaemic attack of undetermined cause found TTE-detected major CSE in only 1% of all patients. Most of these patients also had major ECG abnormalities. These findings question the value of routine TTE assessment in this clinical setting.
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