Yield of Echocardiography with Bubble Studies Among Acute Ischemic Stroke Patients
Jonathan Hu1, Anson Yoong-Chee Lee1, Kazuma Nakagawa2
1John A. Burns School of Medicine, University of Hawaii, Honolulu, HI 96813, USA.
Insights
Bubble studies (BSs) to detect patent foramen ovale (PFO) are overused in stroke patients without cryptogenic stroke (CS), leading to healthcare waste. Guidelines suggest limiting PFO closure to CS patients under 60, yet many BSs are performed inappropriately.
Area of Science:
- Cardiology
- Neurology
- Diagnostic Imaging
Background:
- Transthoracic (TTE) and transesophageal (TEE) echocardiographic bubble studies (BSs) diagnose patent foramen ovale (PFO) in cryptogenic strokes (CS).
- Current guidelines restrict PFO closure recommendations to CS patients aged 60 or younger.
- BSs are frequently performed in older patients or those with known stroke etiologies, irrespective of guidelines.
Purpose of the Study:
- To assess the utilization of echocardiographic bubble studies in acute ischemic stroke patients.
- To evaluate the diagnostic yield and impact on management of BSs in patients with established stroke etiologies versus cryptogenic stroke.
- To identify potential healthcare waste due to overuse of diagnostic studies not aligned with current clinical guidelines.
Main Methods:
- Retrospective single-center study of acute ischemic stroke patients admitted between January 2021 and June 2022.
- Analysis of stroke etiology and the number of TTE and TEE with bubble studies performed.
- Evaluation of PFO diagnoses and subsequent PFO closure procedures.
Main Results:
- Out of 663 patients, 413 (62.3%) had non-cryptogenic stroke (non-CS).
- 390 TTE and 40 TEE with BSs were performed; a significant portion (252 TTE, 17 TEE) were in non-CS patients.
- PFOs were found in 36 CS and 18 non-CS patients, but only 14 PFO closures occurred, primarily in CS patients for stroke prevention.
Conclusions:
- The majority of bubble studies performed in non-CS patients did not alter management, indicating significant diagnostic overuse.
- This overuse contributes to healthcare waste and is not supported by current clinical guidelines for PFO closure.
- Implementing a new institutional protocol is recommended to enhance operational efficiency and reduce unnecessary diagnostic testing in ischemic stroke care.
Abstract:
Background: Transthoracic (TTE) and transesophageal (TEE) echocardiographic studies with agitated saline, also known as "bubble studies" (BSs), are used to diagnose patent foramen ovales (PFOs) in cryptogenic strokes (CSs). Guidelines limit PFO closure recommendations to CS patients ≤ 60 but BSs are often performed as part of standard order sets, leading to inappropriate studies in older patients with already-established stroke etiologies. Methods: This retrospective single-center study included acute ischemic stroke patients between January 2021 and June 2022 and assessed the stroke etiology and number of the echocardiographic studies performed. Results: A total of 663 patients were admitted during this period with 413 (62.3%) classified as non-CS. Overall, 390 (58.8%) TTE and 40 (6.0%) TEE with BSs were conducted. Of that, non-CS patients received 252 TTE and 17 TEE with BSs. PFOs were diagnosed in 36 CS and 18 non-CS patients and 14 of the 15 PFO closures were performed in the CS patients for primary stroke prevention. The one closure in the non-CS patient was performed in conjunction with the open excision of a mitral valve mass. Conclusions: Therefore, the majority of the BSs performed in non-CS patients yielded no change in management. Our study identifies a large volume of diagnostic studies that are not supported by current clinical guidelines and instead, may contribute to healthcare waste. A new institutional protocol should be established to improve operational efficiency and reduce the downstream implications of diagnostic overuse in ischemic stroke care.
More Related Videos
Related Concept Videos
01:20Imaging Studies for Cardiovascular System II:Types of Echocardiography
Types of Echocardiography
Transthoracic Echocardiography (TTE)
TTE is the most common type of echocardiogram which involves placing a transducer on the patient's chest, emitting sound waves to create heart images. TTE is invaluable for evaluating the heart's size, structure, and motion, making it particularly useful for...
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,...
01:22Rheumatic Heart Disease II: Clinical Manifestations and Diagnostic Studies