Original Research

The Value of Routine Transthoracic Echocardiography in Defining the Source of Stroke in a Community Hospital

Journal of Clinical Outcomes Management. 2015 September;22(9)

Author(s):

References

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From Anne Arundel Medical Center, Annapolis, MD.

Abstract

Background: Acute stroke or cerebrovascular accident (CVA) is a common indication for hospitalization and can have devastating consequences, particularly in the setting of recurrence. Cardiac sources are potentially remediable; thus, a transthoracic echocardiogram (TTE) is frequently ordered to evaluate for a cardiac source of embolism.
Objective: To evaluate the utility of performing TTE on patients experiencing a CVA or transient ischemic attack (TIA) to evaluate for a cardiac source of embolism.
Methods: Retrospective review of TTE reports and patient electronic medical records at Anne Arundel Medical Center, a 385-bed community hospital. Medical charts for all CVA patients receiving a TTE between February 2012 to April 2013 were reviewed for TTEs showing unequivocal cardiac sources of embolism as evaluated by the reviewing cardiologist. Patient information and clinical morbidities were also noted to construct a composite demographic of CVA patients.
Results: One TTE of 371 (0.270%) identified a clear cardiac embolus. Risk factors for stroke included hyper-tension ( n = 302), cardiovascular disease ( n = 204), cardiomyopathy ( n = 131), and diabetes ( n = 146).
Conclusion: In the setting of stroke, TTE is of limited value when determining the etiology of stroke and should be used provisionally rather than routinely in evaluating patients experiencing CVA or TIA.

Acute cerebrovascular accident (CVA) is a common indication for hospitalization and can have devastating clinical consequences, particularly in the setting of recurrence. Defining the etiology of CVA and transient ischemic attacks (TIA) when they occur is important so that appropriate therapy can be initiated. Transthoracic echocardiograms (TTEs) are frequently ordered to evaluate for a cardiac source of embolism. No consensus exists about the use of imaging strategies to identify potential cardiovascular sources of emboli in patients who have had strokes.

A few published studies have investigated the yield of TTE in identifying cardiac sources of CVA. The yield has been reported to be between < 1% and as high as 37% [1–3]. However, some of the reported sources of CVA included mitral valve prolapse and patent foramen ovale [4,5], conditions for which the association with stroke has been questioned [6–8]. In addition, many of these studies were performed using clinical data from tertiary referral centers, which may have increased the yield of cardiac sources [9].

The purpose of this study was to evaluate the yield of TTE in evaluating for a clear cardiac source of embolism in a consecutive series of patients diagnosed with a CVA or TIA in a community hospital.

Methods

Setting

All data was collected from the echocardiography lab at Anne Arundel Medical Center, a 384-bed community hospital in Annapolis, MD. The medical center sees about 250 patients a day in its emergency department and admits about 30,000 patients annually. All echocardiograms are performed by a centralized laboratory accredited by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories, which performs approximately 6000 echocardiograms annually.

All TTEs done for the diagnosis of CVA or TIA between 1 February 2013 and 1 May 2013 were evaluated in consecutive fashion by report review. Reports were searched for any cardiac source of embolism to include thrombus, tumor, vegetation, shunt, aortic atheroma, or any other finding that was felt to be a clear source of embolism by the interpreting cardiologist. We did not include entities such as mitral valve prolapse, patent foramen ovale, and isolated atrial septal aneurysms since their association with CVA/TIA has been questioned. Also not included was cardiomyopathy without aneurysm, apical wall motion abnormality, or intra-cavitary thrombus solely because the ejection fraction was less than 35%, as the literature does not support these conditions as clear causes of TIA or CVA.