Title: The value of echocardiography in stroke management
1The value of echocardiography in stroke management
- Asjid Qureshi,
- Specialist registrar to Dr S Nussey
2Echocardiography 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
3Echocardiography 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!
4To estimate the frequency of management altering
abnormal echocardiograms in stroke patients at St
Georges Hospital
Aim of this audit
5Methods
- 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
6Patient details from ward register
Echocardiogram result from cardiology database
7Thomas Young ward register
- Name
- Hospital number
- DOB
- Date of admission/discharge
- Consultant
- Diagnosis
- Follow up arrangements
8Echocardiogram search
- On the hospital number
- Name and/or DOB
9Results
10Admissions
- Number
- Total 103
- Male 56
- Female 47
- Mean no. admissions per month 20
- Mean age 72yrs
- Age range 35-98yrs
11Echocardiogram
- 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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14Echocardiograms
- Echocardiogram
- Total 24
- Entirely normal 10
- Abnormal 14
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16Value of echocardiogram
- 1 in 24 significantly positive result
- Almost 4 yield
Have I just shot myself in the foot?
17Mr DT
- History49 year old AphasiaRight
hemiparesisFebrileFormer IV drug user
18Mr DT
- Examination
- Clubbed, splinter haemorrhagesTemp 39HR
100/minBP 110/58Pan systolic murmur No
splenomegaly - DiagnosisBacterial endocarditis and embolic
CVA - TreatmentIV cefotaxime, flucloxacillin and
gentamicin
19Summary
- 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
20Low Yield of Transthoracic Echocardiography for
Cardiac Source of Embolism
- Vedat Sansoy et al
- American Journal of Cardiology
- 199575166-69
- University of Virginia Medical Centre
21Low 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
22Criteria 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
23Results
- Cases (n1010) Controls (n325)
- Male 521 52 166 51
- Female 489 48 159 49
- Mean age 67yrs 65yrs
24Cases (n1010)
- Number (percentage)
- CVA 677 (67)
- TIA 313 (31)
- Unclear 20 (2)
25Results
- 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
26Results
- Cases Controls
- Atrial fibrillation 14 15
- Systemic hypertension 48 29
- Diabetes mellitus 25 25
- IHD 15 33
- CCF 6 36
27Percentage 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
28Patients 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
29- Management was altered in only 22 of 1010
patients - (2) of whom 17 had pre-existing and known
clinical - and/or electrocardiographic abnormalities
30Other 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
31Conclusion
- 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
32Take 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