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Low yield of transthoracic echocardiography for cardiac source of embolism
V Sansoy1, R D Abbott, A R Jayaweera
1Cardiovascular Division, University of Virginia School of Medicine, Charlottesville.
Insights
Transthoracic echocardiography rarely identifies cardiac sources of embolism in stroke patients. This diagnostic yield is low and similar to individuals without cerebrovascular accidents.
Area of Science:
- Cardiology
- Neurology
- Diagnostic Imaging
Background:
- Cardiac embolism is a potential cause of cerebrovascular accidents (stroke).
- Transthoracic echocardiography is used to identify cardiac sources of embolism.
- The clinical utility of echocardiography in stroke evaluation requires further clarification.
Purpose of the Study:
- To evaluate the diagnostic yield of transthoracic echocardiography for identifying cardiac sources of embolism in patients with cerebrovascular accidents.
- To compare the prevalence of cardiac embolic sources in stroke patients versus controls.
Main Methods:
- Retrospective review of echocardiographic reports from 1,010 patients with cerebrovascular accidents and 325 controls.
- Analysis of predefined echocardiographic findings indicative of embolic potential.
- Adjustment for age and cardiovascular risk factors.
Main Results:
- The prevalence of highly probable cardiac embolic sources was low (<3%) in stroke patients, similar to controls.
- Possible cardiac embolic sources were also found infrequently (<5%) and were similar between groups.
- Echocardiography findings led to therapy changes in only 2% of stroke patients, primarily those with existing heart conditions.
Conclusions:
- Transthoracic echocardiography has a very low yield for detecting significant cardiac sources of embolism in patients presenting with cerebrovascular accidents.
- The prevalence of potential cardiac embolic sources identified by echocardiography is not significantly higher in stroke patients compared to controls.
- Routine echocardiography for stroke workup may not be as impactful as previously assumed, particularly in the absence of specific cardiac risk factors.
Abstract:
To test the hypothesis that the yield for a cardiac source of embolism is very low using transthoracic echocardiography, we reviewed the echocardiographic reports of 1,010 consecutive patients with cerebrovascular accidents who had undergone echocardiography to rule out a cardiac source of embolism; risk factor information was also available in 493 patients. We also used 325 controls who had undergone echocardiography for other reasons during the same period. Each report was examined for the presence of predefined findings depending on their propensity for causing cerebrovascular accidents via an embolic process. The prevalence of a highly probable source of embolism was low in cases (< 3%) and no different from controls after adjusting for age and other risk factors. The prevalence of a possible cardiac source of embolism was also low (< 5%) and similar in cases and controls. The presence of definite or possible thrombus on echocardiography resulted in alteration in therapy in only 2% of cases, of whom 77% had either heart failure, atrial fibrillation, or Q waves on the electrocardiogram. We conclude that the yield of highly probable or possible cardiac source of embolism in patients with cerebrovascular accidents is very low with transthoracic echocardiography, and is no higher than that noted in similar patients without cerebrovascular accidents.