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Meinel TR, Brignoli K, Kielkopf M, Clenin L, Beyeler M, Scutelnic A, Siepen B, Mueller M, Goeldlin M, Seiffge D, Kaesmacher J, Mujanovic A, Belachew NF, Fischer U, Arnold M, Gräni C, Seiler C, Buffle E, Jung S. Yield of Echocardiography in Ischemic Stroke and Patients With Transient Ischemic Attack With Established Indications for Long-Term Direct Oral Anticoagulant Therapy: A Cross-Sectional Diagnostic Cohort Study. J Am Heart Assoc 2022; 11:e024989. [PMID: 35475357 PMCID: PMC9238622 DOI: 10.1161/jaha.121.024989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background We aimed to determine the diagnostic yield of transthoracic (TTE) and transesophageal echocardiography (TEE) in patients with ischemic stroke and transient ischemic attack with established indications for direct oral anticoagulants before the index event. Methods and Results This was a retrospective cohort study of consecutive patients with preceding established indications for long‐term therapeutic direct oral anticoagulants presenting to a single comprehensive stroke center with ischemic stroke or transient ischemic attack. Choice of echocardiography modality was based on expert recommendations. The primary outcome was a composite of prespecified management‐relevant high‐risk findings adjudicated by an expert panel, based on TTE and TEE reports according to evidence‐based recommendations. Explorative analyses were performed to identify biomarkers associated with the primary outcome. Of 424 patients included (median [interquartile range] age, 78 [70–84] years; 175 [41%] women; National Institutes of Health Stroke Scale, 4 [1–12]; 67% atrial fibrillation), 292 (69%) underwent echocardiography, while 132 (31%) did not. Modality was TTE in 191 (45%) and TEE in 101 (24%). Median time from index event to echocardiography was 2 (1–3) days. TTE identified 26 of 191 (14%) patients with 35 management‐relevant pathologies. TEE identified 16 of 101(16%) patients with 20 management‐relevant pathologies. Most management‐relevant findings represented indicated coronary artery disease and valvular pathologies. In a further 3 of 191 (2%) patients with TTE and 4 of 101 (4%) patients with TEE, other relevant findings were identified. Variables associated with management‐relevant high‐risk pathologies included more severe stroke, diabetes, and laboratory biomarkers (NT‐proBNP [N‐terminal pro‐B‐type natriuretic peptide], C‐reactive protein, d‐dimer, and troponin levels). Conclusions In patients with established indications for long‐term direct oral anticoagulant therapy and stroke who received echocardiography, both TTE and TEE identified a relevant and similar proportion of management‐relevant high‐risk pathologies and predictive biomarkers could help to guide diagnostic workup in such patients.
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Affiliation(s)
- Thomas R Meinel
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Kristina Brignoli
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Moritz Kielkopf
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Leander Clenin
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Morin Beyeler
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Adrian Scutelnic
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Bernhard Siepen
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Madlaine Mueller
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Martina Goeldlin
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - David Seiffge
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, InselspitalBern University Hospital Bern Switzerland
| | - Adnan Mujanovic
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland.,Institute of Diagnostic and Interventional Neuroradiology, InselspitalBern University Hospital Bern Switzerland
| | - Nebiyat F Belachew
- Institute of Diagnostic and Interventional Neuroradiology, InselspitalBern University Hospital Bern Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland.,Department of Neurology and Stroke Center University Hospital Basel and University of Basel Basel Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
| | - Christoph Gräni
- Department of Cardiology Inselspital BernBern University Hospital, and University of Bern Bern Switzerland
| | - Christian Seiler
- Department of Cardiology Inselspital BernBern University Hospital, and University of Bern Bern Switzerland
| | - Eric Buffle
- Department of Cardiology Inselspital BernBern University Hospital, and University of Bern Bern Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital Bern University Hospital, and University of Bern Bern Switzerland
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2
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Moores M, Yogendrakumar V, Bereznyakova O, Alesefir W, Thavorn K, Pettem H, Stotts G, Dowlatshahi D, Shamy M. Clinical Utility and Cost of Inpatient Transthoracic Echocardiography Following Acute Ischemic Stroke. Neurohospitalist 2020; 11:12-17. [PMID: 33868551 DOI: 10.1177/1941874420946513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and Purpose It is unclear whether it is clinically necessary or cost-effective to routinely obtain a transthoracic echocardiogram (TTE) during inpatient admission for ischemic stroke. Methods We assessed consecutive patients presenting with acute ischemic stroke at a comprehensive stroke center from 2015 to 2017 who underwent TTE. We assessed for findings on TTE that would warrant urgent intervention including cardiac thrombus, atrial myxoma, mitral stenosis, valve vegetation, valve dysfunction requiring surgery, and low ejection fraction. Subsequent changes in management included changes in anticoagulation, antibiotics, or valve surgery. We calculated in-hospital resource utilization and associated costs for inpatient TTE using individual direct cost details within a case-costing system. Results Of 695 patients admitted with acute ischemic stroke, 516 (74%) had a TTE and were included in our analysis. TTE findings were potentially clinically significant in 30 patients (5.8%) and changed management in 17 patients (3.3%). Inpatient admission was prolonged to expedite TTE in 24 patients, while TTE occurred after discharge in 76 patients. After correcting for the cost of TTE, the mean difference in cost to prolong an admission for TTE was $555.52 (USD), or $16 832 per change in management. Conclusions Given the low clinical utility of inpatient TTE after acute ischemic stroke and the costs associated with prolonging admission, discharge from hospital should not be delayed solely to obtain TTE.
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Affiliation(s)
- Margaret Moores
- Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Vignan Yogendrakumar
- Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Olena Bereznyakova
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital and Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Walid Alesefir
- Department of Neurology, CHUM (Centre hospitalier de l'Université de Montréal), Montreal, Quebec, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, Ottawa, Ontario, Canada
| | - Hailey Pettem
- Champlain Regional Stroke Network, Ottawa, Ontario, Canada
| | - Grant Stotts
- Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Michel Shamy
- Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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4
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Paciaroni M, Agnelli G, Falocci N, Caso V, Becattini C, Marcheselli S, Rueckert C, Pezzini A, Poli L, Padovani A, Csiba L, Szabó L, Sohn SI, Tassinari T, Abdul-Rahim AH, Michel P, Cordier M, Vanacker P, Remillard S, Alberti A, Venti M, Acciarresi M, D'Amore C, Mosconi MG, Scoditti U, Denti L, Orlandi G, Chiti A, Gialdini G, Bovi P, Carletti M, Rigatelli A, Putaala J, Tatlisumak T, Masotti L, Lorenzini G, Tassi R, Guideri F, Martini G, Tsivgoulis G, Vadikolias K, Liantinioti C, Corea F, Del Sette M, Ageno W, De Lodovici ML, Bono G, Baldi A, D'Anna S, Sacco S, Carolei A, Tiseo C, Imberti D, Zabzuni D, Doronin B, Volodina V, Consoli D, Galati F, Pieroni A, Toni D, Monaco S, Baronello MM, Barlinn K, Pallesen LP, Kepplinger J, Bodechtel U, Gerber J, Deleu D, Melikyan G, Ibrahim F, Akhtar N, Lees KR. Prognostic value of trans-thoracic echocardiography in patients with acute stroke and atrial fibrillation: findings from the RAF study. J Neurol 2015; 263:231-237. [PMID: 26566907 DOI: 10.1007/s00415-015-7957-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 10/23/2015] [Accepted: 10/23/2015] [Indexed: 11/25/2022]
Abstract
Anticoagulant therapy is recommended for the secondary prevention of stroke in patients with atrial fibrillation (AF). T he identification of patients at high risk for early recurrence, which are potential candidates to prompt anticoagulation, is crucial to justify the risk of bleeding associated with early anticoagulant treatment. The aim of this study was to evaluate in patients with acute ischemic stroke and AF the association between findings at trans-thoracic echocardiography (TTE) and 90 days recurrence. In consecutive patients with acute ischemic stroke and AF, TTE was performed within 7 days from hospital admission. Study outcomes were recurrent ischemic cerebrovascular events (stroke or TIA) and systemic embolism. 854 patients (mean age 76.3 ± 9.5 years) underwent a TTE evaluation; 63 patients (7.4%) had at least a study outcome event. Left atrial thrombosis was present in 11 patients (1.3%) among whom 1 had recurrent ischemic event. Left atrial enlargement was present in 548 patients (64.2%) among whom 51 (9.3%) had recurrent ischemic events. The recurrence rate in the 197 patients with severe left atrial enlargement was 11.7%. On multivariate analysis, the presence of atrial enlargement (OR 2.13; 95% CI 1.06-4.29, p = 0.033) and CHA2DS2-VASc score (OR 1.22; 95% CI 1.04-1.45, p = 0.018, for each point increase) were correlated with ischemic recurrences. In patients with AF-associated acute stroke, left atrial enlargement is an independent marker of recurrent stroke and systemic embolism. The risk of recurrence is accounted for by severe atrial enlargement. TTE-detected left atrial thrombosis is relatively uncommon.
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Affiliation(s)
- Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Via G. Dottori 1, 06100, Perugia, Italy.
| | - Giancarlo Agnelli
- Stroke Unit and Division of Cardiovascular Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Via G. Dottori 1, 06100, Perugia, Italy
| | - Nicola Falocci
- Stroke Unit and Division of Cardiovascular Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Via G. Dottori 1, 06100, Perugia, Italy
| | - Valeria Caso
- Stroke Unit and Division of Cardiovascular Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Via G. Dottori 1, 06100, Perugia, Italy
| | - Cecilia Becattini
- Stroke Unit and Division of Cardiovascular Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Via G. Dottori 1, 06100, Perugia, Italy
| | - Simona Marcheselli
- Neurologia d'urgenza e Stroke Unit, Istituto Clinico Humanitas, Rozzano, Milan, Italy
| | | | - Alessandro Pezzini
- Neurology Unit, Department of Clinical and Experimental Sciences, University "Health and Wealth" of Brescia, Brescia, Italy
| | - Loris Poli
- Neurology Unit, Department of Clinical and Experimental Sciences, University "Health and Wealth" of Brescia, Brescia, Italy
| | - Alessandro Padovani
- Neurology Unit, Department of Clinical and Experimental Sciences, University "Health and Wealth" of Brescia, Brescia, Italy
| | - Laszló Csiba
- Stroke Unit, University of Debrecen, Debrecen, Hungary
| | - Lilla Szabó
- Stroke Unit, University of Debrecen, Debrecen, Hungary
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University School of Medicine, Taegu, South Korea
| | - Tiziana Tassinari
- Stroke Unit-Department of Neurology, Santa Corona Hospital, Pietra Ligure, Savona, Italy
| | - Azmil H Abdul-Rahim
- Medical School and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Patrik Michel
- Centre Cérébrovasculaire, Service de Neurologie, Département des Neurosciences Cliniques Centre Hopitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Maria Cordier
- Centre Cérébrovasculaire, Service de Neurologie, Département des Neurosciences Cliniques Centre Hopitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Peter Vanacker
- Department of Neurology, Born Bunge Institute, Antwerp University Hospital, Antwerp, Belgium
| | - Suzette Remillard
- Centre Cérébrovasculaire, Service de Neurologie, Département des Neurosciences Cliniques Centre Hopitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Andrea Alberti
- Stroke Unit and Division of Cardiovascular Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Via G. Dottori 1, 06100, Perugia, Italy
| | - Michele Venti
- Stroke Unit and Division of Cardiovascular Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Via G. Dottori 1, 06100, Perugia, Italy
| | - Monica Acciarresi
- Stroke Unit and Division of Cardiovascular Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Via G. Dottori 1, 06100, Perugia, Italy
| | - Cataldo D'Amore
- Stroke Unit and Division of Cardiovascular Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Via G. Dottori 1, 06100, Perugia, Italy
| | - Maria Giulia Mosconi
- Stroke Unit and Division of Cardiovascular Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Via G. Dottori 1, 06100, Perugia, Italy
| | - Umberto Scoditti
- Stroke Unit, Neuroscience Department, University of Parma, Parma, Italy
| | - Licia Denti
- Stroke Unit, Dipartimento Geriatrico Riabilitativo, University of Parma, Parma, Italy
| | - Giovanni Orlandi
- Clinica Neurologica, Azienda Ospedaliero-Universitaria, Pisa, Italy
| | - Alberto Chiti
- Clinica Neurologica, Azienda Ospedaliero-Universitaria, Pisa, Italy
| | - Gino Gialdini
- Clinica Neurologica, Azienda Ospedaliero-Universitaria, Pisa, Italy
| | - Paolo Bovi
- SSO Stroke Unit, UO Neurologia, DAI di Neuroscienze, AOUI Verona, Verona, Italy
| | - Monica Carletti
- SSO Stroke Unit, UO Neurologia, DAI di Neuroscienze, AOUI Verona, Verona, Italy
| | - Alberto Rigatelli
- SSO Stroke Unit, UO Neurologia, DAI di Neuroscienze, AOUI Verona, Verona, Italy
| | - Jukka Putaala
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
- Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Göteborg, Göteborg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Luca Masotti
- Department of Internal Medicine, Cecina Hospital, Cecina, Livorno, Italy
| | - Gianni Lorenzini
- Department of Internal Medicine, Cecina Hospital, Cecina, Livorno, Italy
| | | | | | | | - Georgios Tsivgoulis
- Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupoli, Greece
- International Clinic Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
- Second Department of Neurology, "Attikon" Hospital, University of Athens, School of Medicine, Athens, Greece
| | - Kostantinos Vadikolias
- Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupoli, Greece
| | - Chrissoula Liantinioti
- Second Department of Neurology, "Attikon" Hospital, University of Athens, School of Medicine, Athens, Greece
| | - Francesco Corea
- UO Gravi Cerebrolesioni, San Giovanni Battista Hospital, Foligno, Italy
| | - Massimo Del Sette
- Stroke Unit, Department of Neurology, Sant'Andrea Hospital, La Spezia, Italy
| | - Walter Ageno
- Department of Internal Medicine, Insubria University, Varèse, Italy
| | | | - Giorgio Bono
- Stroke Unit, Neurology, Insubria University, Varèse, Italy
| | - Antonio Baldi
- Stroke Unit, Ospedale di Portogruaro, Portogruaro, Venice, Italy
| | | | - Simona Sacco
- Department of Neurology, University of L'Aquila, L'Aquila, Italy
| | - Antonio Carolei
- Department of Neurology, University of L'Aquila, L'Aquila, Italy
| | - Cindy Tiseo
- Department of Neurology, University of L'Aquila, L'Aquila, Italy
| | - Davide Imberti
- Department of Internal Medicine, Ospedale Civile di Piacenza, Piacenza, Italy
| | - Dorjan Zabzuni
- Department of Internal Medicine, Ospedale Civile di Piacenza, Piacenza, Italy
| | - Boris Doronin
- Municipal Budgetary Healthcare Institution of Novosibirsk, City Clinical Hospital #1, Novosibirsk, Russia
| | - Vera Volodina
- Municipal Budgetary Healthcare Institution of Novosibirsk, City Clinical Hospital #1, Novosibirsk, Russia
| | | | - Franco Galati
- Stroke Unit, Jazzolino Hospital, Vibo Valentia, Italy
| | - Alessio Pieroni
- Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Danilo Toni
- Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | | | | | - Kristian Barlinn
- Department of Neurology, Dresden University Stroke Center, Dresden, Germany
| | | | - Jessica Kepplinger
- Department of Neurology, Dresden University Stroke Center, Dresden, Germany
| | - Ulf Bodechtel
- Department of Neurology, Dresden University Stroke Center, Dresden, Germany
| | - Johannes Gerber
- Department of Neurology, Dresden University Stroke Center, Dresden, Germany
| | - Dirk Deleu
- Department of Neurology, Hamad Medical Corporation, Doha, Qatar
| | - Gayane Melikyan
- Department of Neurology, Hamad Medical Corporation, Doha, Qatar
| | - Faisal Ibrahim
- Department of Neurology, Hamad Medical Corporation, Doha, Qatar
| | - Naveed Akhtar
- Department of Neurology, Hamad Medical Corporation, Doha, Qatar
| | - Kennedy R Lees
- Medical School and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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