Limitations of transoesophageal echocardiogram in acute ischaemic stroke

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.

[1]  T. Steiner,et al.  Patent Foramen Ovale: Story Closed? , 2019, Journal of stroke.

[2]  P. Grayburn,et al.  Utility of routine transesophageal echocardiography in patients with stroke or transient ischemic attack , 2018, Proceedings.

[3]  W. Powers,et al.  2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association , 2018, Stroke.

[4]  L. Fleisher,et al.  2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. , 2017, Journal of the American College of Cardiology.

[5]  R Wachter,et al.  Vorhofflimmern besser erkennen, hilft Schlaganfälle zu verhindern , 2017 .

[6]  Klaus Gröschel,et al.  Holter-electrocardiogram-monitoring in patients with acute ischaemic stroke (Find-AFRANDOMISED): an open-label randomised controlled trial , 2017, The Lancet Neurology.

[7]  A. Alexandrov,et al.  The value of transesophageal echocardiography for embolic strokes of undetermined source , 2016, Neurology.

[8]  T. Siepmann,et al.  Diagnostic Impact of Transesophageal Echocardiography in Patients with Acute Cerebral Ischemia , 2016, Echocardiography.

[9]  G. Bernardini,et al.  Impact of transesophageal echocardiography on clinical management of patients over age 50 with cryptogenic stroke and normal transthoracic echocardiogram. , 2016, Journal of Hospital Medicine.

[10]  Mark D. Huffman,et al.  Heart Disease and Stroke Statistics—2016 Update: A Report From the American Heart Association , 2016, Circulation.

[11]  Frank Beckers,et al.  Cryptogenic stroke and underlying atrial fibrillation. , 2014, The New England journal of medicine.

[12]  David J Gladstone,et al.  Atrial fibrillation in patients with cryptogenic stroke. , 2014, The New England journal of medicine.

[13]  M. Wolzt,et al.  Antiplatelet Treatment for Prevention of Cerebrovascular Events in Patients With Vascular Diseases: A Systematic Review and Meta-Analysis , 2014, Stroke.

[14]  Liping Liu,et al.  Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. , 2013, The New England journal of medicine.

[15]  M. Wintermark,et al.  Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association , 2013, Stroke.

[16]  A. Pellisé,et al.  Cardiac Workup of Ischemic Stroke , 2010, Current cardiology reviews.

[17]  M. Fisher,et al.  Cardiac Workup of Ischemic Stroke: Can We Improve Our Diagnostic Yield? , 2009, Stroke.

[18]  Patrice Cacoub,et al.  Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. , 2006, The New England journal of medicine.

[19]  A. Geibel,et al.  Therapeutic Strategies After Examination by Transesophageal Echocardiography in 503 Patients With Ischemic Stroke , 2006, Stroke.

[20]  H. Diener,et al.  Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial , 2004, The Lancet.

[21]  Olaf Gefeller,et al.  Epidemiology of Ischemic Stroke Subtypes According to TOAST Criteria: Incidence, Recurrence, and Long-Term Survival in Ischemic Stroke Subtypes: A Population-Based Study , 2001, Stroke.

[22]  David Lee Gordon,et al.  Classification of Subtype of Acute Ischemic Stroke: Definitions for Use in a Multicenter Clinical Trial , 1993, Stroke.

[23]  R. Grimm,et al.  Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism. , 2016, Journal of the American Society of Echocardiography.