The value of echocardiography in stroke management

Asjid Qureshi,

Specialist registrar to Dr S Nussey

Echocardiography at St George’s 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

Echocardiography in stroke management at St George’s 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!

To estimate the frequency of management altering abnormal echocardiograms in stroke patients at St

George’s Hospital

Aim of this audit

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

Patient details from ward register

Abnormal echocardiogram report?

No

Management altering abnormality?

Yes

NoYes

Did it alter management?

Echocardiogram result from cardiology database

Thomas Young ward register

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

Echocardiogram search

• On the hospital number

• Name and/or DOB

Results

Admissions

Number

Total 103

Male 56

Female 47

Mean no. admissions per month 20

Mean age 72yrs

Age range 35-98yrs

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

Admissions per consultant

14

10

8

10

7

9

6

12

6

1

15

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4 0 2 1 0 2 2 3 3 1 3

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10

6

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7

7

4

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No echoEcho

Echocardiograms

Echocardiogram

Total 24

Entirely normal 10

Abnormal 14

Echocardiogram results

10

4

2

1

3

1

11

1 Normal

Mild LV/LA dilatation

Sclerotic AV

Patent foramen Ovale

LVH

Aortic stenosis

Mildly dilated prox.Aorta

Vegetation

Moderate MR

Value of echocardiogram

• 1 in 24 significantly positive result

• Almost 4% yield

Have I just shot myself in the foot?

Mr DT

History49 year old AphasiaRight hemiparesisFebrileFormer IV drug user

Mr DT

Examination

Clubbed, splinter haemorrhagesTemp 39HR 100/minBP 110/58Pan systolic murmur No splenomegaly

Diagnosis“Bacterial endocarditis and embolic CVA”

TreatmentIV cefotaxime, flucloxacillin and gentamicin

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

Low Yield of Transthoracic Echocardiography for Cardiac Source of Embolism

Vedat Sansoy et al

American Journal of Cardiology

1995;75:166-69

University of Virginia Medical Centre

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

Criteria used for determining cardiac source of embolism

Highly probable causes: Definite left ventricularDefinite left atrial thrombusDefinite left atrial myxomaDefinite valvular vegetation

Possible causes: Possible left ventricularPossible left atrial thrombusPossible valvular vegetationAtrial septal defect

Doubtful causes: Mitral valve prolapse

Mitral annular calcification

Results

Cases (n=1010) Controls (n=325)

Male 521 [52%] 166 [51%]

Female 489 [48%] 159 [49%]

Mean age 67yrs 65yrs

Cases (n=1010)

Number (percentage)

CVA 677 (67%)

TIA 313 (31%)

Unclear 20 (2%)

Results

CasesControls

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%

Results

Cases Controls

Atrial fibrillation 14% 15%

Systemic hypertension 48% 29%

Diabetes mellitus 25% 25%

IHD 15% 33%

CCF 6% 36%

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

CasesControls

Definite cardiac source 5% 5%

Probable cardiac source 4% 4%

Doubtful cardiac source 37% 30%

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

Management was altered in only 22 of 1010 patients

(2%) of whom 17 had pre-existing and known clinical

and/or electrocardiographic abnormalities

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

Conclusion• Limited resources in echocardiogram department

• Over 25% of patients with a CVA receive an

echocardiogram at St George’s 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

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