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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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Num
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of p
atie
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Echocardiograms per consultant
4 0 2 1 0 2 2 3 3 1 3
10
10
6
9
7
7
4
9
3
0
12
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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