Transesophageal echocardiography (TEE) is frequently performed in patients with acute ischemic cerebrovascular events to exclude a cardioembolic source. We aimed to determine the clinical impact of TEE on management. This is a retrospective single-center study of 1,458 consecutive patients hospitalized with acute ischemic stroke or transient ischemic attack who underwent TEE for evaluation of a suspected cardioembolic cause. Significant TEE findings were determined for each patient as recorded on the TEE report. The medical record was reviewed for baseline, clinical, and demographic variables and to determine whether significant management changes occurred as a result of the TEE findings. Potential significant changes in management included initiation of anticoagulation, placement of a patent foramen ovale (PFO) closure device, initiation of antibiotic therapy for endocarditis, surgical PFO closure, other cardiac surgery, and coil embolization of a pulmonary arteriovenous malformation. A significant change in management occurred in 243 patients (16.7%); 173 (71%) underwent treatment for PFO with a percutaneous PFO closure device (n = 100), initiation of chronic systemic anticoagulation (n = 68), or surgical PFO closure (n = 5). Additional findings leading to a change in management included endocarditis (n = 20), aortic arch atheroma (n = 14), intracardiac thrombus (n = 13), pulmonary arteriovenous malformation (n = 2), aortic valve fibroelastoma (n = 2), other valve masses (n = 4), and miscellaneous causes (n = 15). In conclusion, in patients with suspected cardioembolic stroke, TEE findings led to a change in management in 16.7% of patients. Of these, most (71%) were directed at prevention of subsequent paradoxical emboli in patients with PFO.
Approximately 700,000 ischemic strokes occur each year in the United States; of these, approximately 20% to 40% are believed secondary to a cardioembolic cause. Transesophageal echocardiography (TEE) is frequently performed in this patient population in an effort to elucidate a specific cause. Although previous studies indicate that a potential cardioembolic source is frequently identified, the impact of these findings on management has not been well described. Although TEE is a “noninvasive” diagnostic test, serious complications occur in about 1 in 500 examinations, with death in about 1 in 10,000 studies. In addition to these safety considerations, TEE is resource intensive (generally involving a nurse, sonographer, and physician) and has the need for conscious sedation and continuous hemodynamic monitoring during the examination and recovery period. Given these considerations, it seems prudent to identify which patients with stroke likely benefit most from TEE and which patients might safely defer TEE due to a low likelihood of therapy altering test findings. The objective of this study was to determine the incidence of patient management change due to TEE findings in a large consecutive cohort of patients hospitalized with acute ischemic stroke and a suspected cardioembolic cause.
Methods
This is a single-center, retrospective study. The Saint Luke’s Hospital of Kansas City’s Institutional Review Board approved the study. We included hospitalized patients who underwent TEE from October 2000 to August 2012 at a Saint Luke’s Hospital System facility for an indication of stroke (Cerebrovascular accident, International Classification of Diseases-9 code 436). Patients were excluded if they did not have a documented ischemic stroke or transient ischemic attack, or if the stroke was hemorrhagic. TEE reports were reviewed for each patient, and echocardiographic findings were entered into a database. The medical record was also reviewed for the index hospital admission, and clinical and demographic variables were also entered into the same database. Finally, the medical record was reviewed to determine whether management was impacted by the TEE results. Potential management changes included initiation of chronic oral anticoagulation, placement of a patent foramen ovale (PFO) closure device, initiation of intravenous antibiotics for treatment of endocarditis, surgical PFO closure, other cardiac surgery, or coil embolization of a pulmonary arteriovenous malformation. Initiation of antiplatelet therapy (either aspirin alone or dual antiplatelet therapy), antihypertensive medications, and lipid lowering drugs were all considered standard of care secondary prevention therapies and were not considered a significant change in management. If a patient had a preexisting indication for chronic oral anticoagulation (including paroxysmal atrial fibrillation or atrial flutter during the index admission), initiation of chronic oral anticoagulation for other TEE findings was not considered a change in management. If a TEE diagnosis led to a change in management, but that same diagnosis was noted on a transthoracic echocardiographic study during the index admission, a significant change in management due to TEE findings was not considered present. Clinical and demographic data for each patient were compared between the group of patients with a change in management versus the group of patients with no change in management. Across the 2 groups, continuous variables were compared using the student’s t test, whereas categorical variables were compared using the chi-square or Fisher’s exact test, as appropriate. To predict change in management, a logistic regression model was developed with the following covariates: age, gender, left ventricular ejection fraction, hypertension, diabetes mellitus, coronary artery disease, heart failure, dyslipidemia, current smoking, peripheral arterial disease, previous stroke, previous percutaneous coronary intervention, previous coronary artery bypass grafting, and current medication use including aspirin, statins, other lipid lowering medications, β blockers, and angiotensin converting enzyme inhibitors. In the subjects with a change in management, an additional logistic regression model was developed to determine significant predictors of PFO closure usage. Statistical significance was defined as p <0.05 and all statistical analyses were performed using SAS v9.3 (SAS Institute, Cary, North Carolina).
Results
From October 2000 to August 2012, a total of 1,458 hospitalized patients underwent TEE for evaluation of documented acute ischemic stroke or transient ischemic attack. Baseline demographic characteristics of the group with change in management versus the group with no change in management are listed in Table 1 . A significant change in management occurred in 243 patients (16.7%; Tables 2 and 3 ). Therapeutic change as a result of TEE findings was very common in patients <40 years of age (32% of patients), decreasing in frequency with each decade of life ( Figure 1 ). Multivariable analysis predictors of change in management are listed in Table 4 .
| Baseline Demographics | TEE Impact | P-Value | |
|---|---|---|---|
| Yes | No | ||
| (n = 243) | (n = 1215) | ||
| Age (Years) | 56.1 ± 16.6 (range 17-93) | 61.4 ± 14.7 (range 18-93) | < 0.001 |
| Male | 141 (58.0%) | 651 (53.6%) | 0.204 |
| Female | 102 (42.0%) | 564 (46.4%) | |
| Hypertension | 141 (58.0%) | 855 (70.4%) | < 0.001 |
| Diabetes mellitus | 45 (18.5%) | 338 (27.9%) | 0.003 |
| Coronary artery disease | 52 (21.4%) | 304 (25.0%) | 0.23 |
| Heart Failure | 28 (11.6%) | 109 (9.1%) | 0.226 |
| Peripheral Artery Disease | 56 (23.4%) | 419 (35.0%) | < 0.001 |
| Atrial fibrillation | 4 (1.7%) | 174 (14.5%) | <0.001 |
| Left ventricular ejection fraction | 56.7 ± 12.3 | 59.0 ± 9.5 | 0.001 |
| Dyslipidemia ∗ | 167 (68.7%) | 933 (77.4%) | 0.004 |
| Prior stroke | 48 (19.8%) | 326 (27.0%) | 0.02 |
| Prior coronary bypass | 24 (9.9%) | 106 (8.8%) | 0.573 |
| Family history of coronary artery disease ∗ | 128 (59.8%) | 677 (60.9%) | 0.758 |
| Smoker | 123 (51.7%) | 660 (54.8%) | 0.375 |
| Hypercoagulable state | 17 (11.6%) | 80 (9.8%) | 0.501 |
| Aspirin on admission | 81 (34.0%) | 515 (42.7%) | 0.013 |
| Other antiplatelet drug on admission | 29 (12.2%) | 169 (14.0%) | 0.462 |
| Statin on admission | 55 (23.2%) | 393 (32.7%) | 0.004 |
| Other cholesterol lowering drug on admission | 17 (7.2%) | 89 (7.5%) | 0.877 |
| Beta blocker on admission | 56 (23.9%) | 359 (30.0%) | 0.063 |
| ACEI or ARB on admission | 80 (34.0%) | 444 (37.2%) | 0.365 |
| Aspirin at dismissal | 161 (68.5%) | 894 (75.8%) | 0.019 |
| Other antiplatelet drug at dismissal | 68 (29.1%) | 485 (41.4%) | < 0.001 |
| Statin drug at dismissal | 142 (60.7%) | 815 (69.8%) | 0.006 |
| Beta blocker at dismissal | 73 (31.2%) | 443 (37.9%) | 0.053 |
| ACEI or ARB at dismissal | 94 (40.2%) | 537 (46.0%) | 0.103 |
| Diagnosis | Total n = 243 | Age (Years) | P-Value | ||||
|---|---|---|---|---|---|---|---|
| <40(n = 40) | 40-49(n = 48) | 50-59(n = 51) | 60-69(n = 46) | ≥70(n = 58) | |||
| Patent foramen ovale | 173 (71.2%) | 32 (80.0%) | 37 (77.1%) | 36 (70.6%) | 28 (60.9%) | 40 (69.0%) | 0.301 |
| Infective endocarditis | 20 (8.2%) | 5 (12.5%) | 4 (8.3%) | 4 (7.8%) | 2 (4.3%) | 5 (8.6%) | 0.764 |
| Aortic arch atheroma | 14 (5.8%) | 0 (0.0%) | 1 (2.1%) | 3 (5.9%) | 5 (10.9%) | 5 (8.6%) | 0.136 |
| LA appendage thrombus | 8 (3.3%) | 0 (0.0%) | 0 (0.0%) | 2 (3.9%) | 4 (8.7%) | 2 (3.4%) | 0.125 |
| LA mass | 1 (0.4%) | 0 (0.0%) | 0 (0.0%) | 1 (2.0%) | 0 (0.0%) | 0 (0.0%) | 0.761 |
| Descending aorta thrombus | 3 (1.2%) | 0 (0.0%) | 0 (0.0%) | 1 (2.0%) | 1 (2.2%) | 1 (1.7%) | 0.940 |
| LV aneurysm | 1 (0.4%) | 0 (0.0%) | 0 (0.0%) | 1 (2.0%) | 0 (0.0%) | 0 (0.0%) | 0.761 |
| LV systolic dysfunction | 8 (3.3%) | 1 (2.5%) | 2 (4.2%) | 0 (0.0%) | 4 (8.7%) | 1 (1.7%) | 0.165 |
| Valve mass | 4 (1.6%) | 2 (5.0%) | 0 (0.0%) | 0 (0.0%) | 1 (2.2%) | 1 (1.7%) | 0.298 |
| LV thrombus | 2 (0.8%) | 0 (0.0%) | 0 (0.0%) | 2 (3.9%) | 0 (0.0%) | 0 (0.0%) | 0.143 |
| Biatrial dilatation | 1 (0.4%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 1 (1.7%) | 1.000 |
| Aortic valve fibroelastoma | 2 (0.8%) | 0 (0.0%) | 1 (2.1%) | 0 (0.0%) | 0 (0.0%) | 1 (1.7%) | 0.899 |
| ASD closure device fracture | 2 (0.8%) | 0 (0.0%) | 0 (0.0%) | 1 (2.0%) | 1 (2.2%) | 0 (0.0%) | 0.631 |
| Pacemaker lead thrombus | 2 (0.8%) | 0 (0.0%) | 2 (4.2%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0.100 |
| Pulmonary AVM | 2 (0.8%) | 0 (0.0%) | 1 (2.1%) | 0 (0.0%) | 0 (0.0%) | 1 (1.7%) | 0.899 |
| Therapy | Total n = 243 | Age (Years) | P-Value | ||||
|---|---|---|---|---|---|---|---|
| <40(n = 40) | 40-49(n = 48) | 50-59(n = 51) | 60-69(n = 46) | ≥70(n = 58) | |||
| Anticoagulation | 115 (47.3%) | 8 (20.0%) | 19 (39.6%) | 25 (49.0%) | 29 (63.0%) | 34 (58.6%) | < 0.001 |
| PFO closure device | 100 (41.2%) | 24 (60.0%) | 22 (45.8%) | 22 (43.1%) | 14 (30.4%) | 18 (31.0%) | 0.026 |
| Antibiotic therapy | 10 (4.1%) | 1 (2.5%) | 4 (8.3%) | 2 (3.9%) | 1 (2.2%) | 2 (3.4%) | 0.672 |
| Surgical PFO closure | 5 (2.1%) | 3 (7.5%) | 1 (2.1%) | 1 (2.0%) | 0 (0.0%) | 0 (0.0%) | 0.079 |
| Cardiac Surgery | 12 (4.9%) | 4 (10.0%) | 1 (2.1%) | 1 (2.0%) | 2 (4.3%) | 4 (6.9%) | 0.385 |
| Coil embolization | 1 (0.4%) | 0 (0.0%) | 1 (2.1%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | |
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