The value of echocardiography in stroke management

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The value of echocardiography in stroke management

• Asjid Qureshi,
• Specialist registrar to Dr S Nussey

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Echocardiography at St Georges Hospital

• Each echocardiogram is estimated to cost 55
• 12,000 requests are received per year
• Total cost of 660,000
• 30-35 echocardiograms performed per day
• Average outpatient wait for routine echo is 6
  weeks
• Only urgent inpatient echos are done during
  admission

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Echocardiography in stroke management at St
Georges Hospital

• Already a filtering system in place
• Only those with a cardiac history (AF, previous
  MI, murmur) are accepted
• Those requests without this are filtered out,
  unless you persist!

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To estimate the frequency of management altering
abnormal echocardiograms in stroke patients at St
Georges Hospital
Aim of this audit
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Methods

• All admissions to Thomas Young Ward
• Between 1-1-01 and 1-6-01
• Details from ward register
• Search for echocardiogram results on all
• Review appropriate notes

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Patient details from ward register
Echocardiogram result from cardiology database
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Thomas Young ward register

• Name
• Hospital number
• DOB
• Date of admission/discharge
• Consultant
• Diagnosis
• Follow up arrangements

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Echocardiogram search

• On the hospital number
• Name and/or DOB

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Results
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Admissions

• Number
• Total 103
• Male 56
• Female 47
• Mean no. admissions per month 20
• Mean age 72yrs
• Age range 35-98yrs

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Echocardiogram

• Echocardiogram No echocardiogram
• Total 24(23.3) 79(76.7)
• Male 15(26.8) 41(73.2)
• Female 9(19.1) 38(80.9)
• Mean age 66yrs 74yrs
• Age range 35-90yrs 48-98yrs

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Echocardiograms

• Echocardiogram
• Total 24
• Entirely normal 10
• Abnormal 14

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Value of echocardiogram

• 1 in 24 significantly positive result
• Almost 4 yield

Have I just shot myself in the foot?
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Mr DT

• History49 year old AphasiaRight
  hemiparesisFebrileFormer IV drug user

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Mr DT

• Examination
• Clubbed, splinter haemorrhagesTemp 39HR
  100/minBP 110/58Pan systolic murmur No
  splenomegaly
• DiagnosisBacterial endocarditis and embolic
  CVA
• TreatmentIV cefotaxime, flucloxacillin and
  gentamicin

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Summary

• 103 stroke patients admitted to Thomas Young ward
• 24 had echocardiograms performed
• Far more requested though!
• 10 were entirely normal
• Only 1 had a results that would alter management
• Clinical features in that case completely
  supported the request for an echocardiogram

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Low Yield of Transthoracic Echocardiography for
Cardiac Source of Embolism

• Vedat Sansoy et al
• American Journal of Cardiology
• 199575166-69
• University of Virginia Medical Centre

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Low Yield of Transthoracic Echocardiography for
Cardiac Source of Embloism

• 1,010 consecutive patients admitted with CVAs or
  TIAs
• 325 controls
• Exclusion criteria MI within the prior 6weeks,
  orknown bacterial endocarditis

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Criteria used for determining cardiac source of
embolism

• Highly probable causes Definite left
  ventricular Definite left atrial
  thrombus Definite left atrial myxoma Definite
  valvular vegetation
• Possible causes Possible left ventricular Possib
  le left atrial thrombus Possible valvular
  vegetation Atrial septal defect
• Doubtful causes Mitral valve prolapse
• Mitral annular calcification

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Results

• Cases (n1010) Controls (n325)
• Male 521 52 166 51
• Female 489 48 159 49
• Mean age 67yrs 65yrs

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Cases (n1010)

• Number (percentage)
• CVA 677 (67)
• TIA 313 (31)
• Unclear 20 (2)

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Results

• Cases Controls
• Definite left ventricular thrombus 2.8 5.2
• Definite left atrial thrombus 0.0 0.0
• Definite valvular vegetation 0.0 2.5
• Left atrial myxoma 0.0 0.0
• Possible left ventricular thrombus 2.0 3.0
• Possible left atrial thrombus 0.3 0.0
• Possible valvular vegetation 2.0 2.0
• Atrial septal defect 0.3 0.6
• Mitral valve prolapse 5.0 5.0
• Mitral annular calcification 31.0 26.0

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Results

• Cases Controls
• Atrial fibrillation 14 15
• Systemic hypertension 48 29
• Diabetes mellitus 25 25
• IHD 15 33
• CCF 6 36

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Percentage of patients with definite, probable
and doubtful cardiac source of embolus as
determined by Transthoracic two-dimensional
Echocardiography after adjustment for age and
various cardiovascular conditions

• Cases Controls
• Definite cardiac source 5 5
• Probable cardiac source 4 4
• Doubtful cardiac source 37 30

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Patients anticoagulated following a positive
echocardiograph result

• Cases
• Definite cardiac source 50
• Probable cardiac source 30
• Doubtful cardiac source 0
• The remainder were not treated with
  anticoagulants because of
• contraindications that were known before
  echocardiography

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• Management was altered in only 22 of 1010
  patients
• (2) of whom 17 had pre-existing and known
  clinical
• and/or electrocardiographic abnormalities

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Other findings in cases of definite or possible
thrombus

• Definite Possible
• Q waves on ECG 54 41
• LBBB 18 11
• CCF 43 26
• AF 25 30
• Only 23 had none of these abnormalities

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Conclusion

• Limited resources in echocardiogram department
• Over 25 of patients with a CVA receive an
  echocardiogram at St Georges Hospital
• It is very unlikely to alter management
• Long outpatient waits for echocardiograms
• Only urgent echos performed as inpatient
• Echocardiography in CVA management is an area
  were there is a need to rationalize our requests

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Take home message

• Low yield for transthoracic echocardiography in
  stroke management
• Most cases have other cardiological
  features/abnormalities
• Echocardiography is a valuable and over used
  resource
• We need to be far more selective in our use of
  echocardiography in stroke management
• Long waiting lists for routine echocardiography
  could be improved as a result