TTE is relatively quick to perform and interpret and carries no physical risk to a patient. However, our data suggest that ordering TTE routinely in the setting of CVA offers little value. With health care organizations turning their attention to reducing low-value care, which potentially wastes limited resources, considerations of value and effectiveness continue to be a priority. Our findings suggest TTE use in this setting conflicts with the current trajectory of value-based medical practice. As well, a prior Markov model decision analysis found that TTE is not cost-effective when used routinely to identify source of emboli in stroke [14].
Despite the low yield of TTE in evaluating for a cardiac source of CVA, TTEs continue to be frequently ordered. In our own institution, 48% of patients with a CVA or TIA underwent a TTE based on preferences and habits of individual admitting physicians and without any structured criteria. Order sets for CVA admissions do not include this test; physicians are adding it but not for any particular patient characteristic or exam finding.
There are a number of reasons that echocardiograms may be ordered more frequently by some. A documented decline in ordering echocardiograms was seen following education at one center [15], suggesting that lack of knowledge about the limitations of TTE may be a factor. A second potential factor is fear of medicolegal consequences. Indeed, the current American Heart Association/American Stroke Association guidelines for the early management of adults with ischemic stroke [16] offers no formal recommendations or clear indications.
Computerized decision support (CDS) that links the medical record to appropriateness criteria could potentially reduce the inappropriate use of TTE. CDS has been shown to be effective in reducing unnecessary ordering of tests in other settings [17–19].
Among the limitations in our analysis is the heterogeneity in echocardiogram readers. However, this heterogeneity may makes the study more relevant as it reflects the reality in most community hospitals. Another potential limitation is that saline contrast studies were not used routinely; however, this too is typical at community hospitals. Also, while all echocardiograms were interpreted by “board-certified” cardiologists, only 5 had passed the “examination of special competence” to be certified as a testamur of the National Board of Echocardiography, raising the question as to whether subtle findings could have been missed. However, there were no relevant findings in the 20% of studies interpreted by the testamurs, suggesting that the other echocardiographers were not missing diagnoses. Finally, we had only 10 patients younger than age 45 and so the study conclusions are less definitive for that age-group.
Conclusion
TTE was of limited utility in uncovering a cardiac source of embolism in a typical population with CVA or TIA.Based upon the data, we believe that TTE should not be used routinely in the setting of CVA; however, we do recognize that TTE may be of value in patients who have other comorbidities that would place them at increased risk of embolic CVA such as a recent anterior MI, those at risk for endocarditis, or those with brain imaging findings suggestive of embolic CVA [20]. Ordering a low-value test such as a TTE in the setting of TIA or CVA adds cost and does not often yield a clinically meaningful results. In addition, a “negative” TTE can be misinterpreted as a normal heart and forestall additional workup such as transesophageal echocardiography and long-term rhythm analysis, which may be of higher value. We suggest that in a community hospital setting the determination of need for TTE be made based on the clinical nuances of the case rather than by habit or as part of standardized order sets.