What is the management plan for a 71-year-old female patient with a history of slurred speech, now resolved, followed by shortness of breath (sob) and dysarthria, presenting with facial deviation to the right and elevated N-terminal pro b-type natriuretic peptide (NT-proBNP) levels?

Management of Acute Neurological Event with Cardiac Findings

This patient requires immediate stroke protocol activation with urgent brain imaging (CT/MRI) and cardioembolic workup, as the combination of resolved dysarthria, facial deviation, and elevated NT-proBNP strongly suggests a cardioembolic stroke or TIA with underlying cardiac dysfunction.

Immediate Diagnostic Priorities

Neurological Assessment

• Activate acute stroke protocol immediately - the transient slurred speech (now resolved) with persistent facial deviation indicates either completed stroke or high-risk TIA 1
• Obtain urgent non-contrast head CT to rule out hemorrhage, followed by MRI with diffusion-weighted imaging to detect acute ischemia 1
• The pattern of transient focal symptoms followed by persistent facial deviation suggests evolving cerebrovascular pathology requiring immediate intervention 2

Cardiac Evaluation for Embolic Source

• The elevated NT-proBNP is a critical finding - it indicates underlying cardiac dysfunction that may be the embolic source 1
• Obtain urgent transthoracic echocardiography within 24 hours to assess:
  • Left ventricular systolic function and ejection fraction
  • Left atrial size and presence of thrombus
  • Valvular abnormalities (particularly mitral valve)
  • Regional wall motion abnormalities suggesting prior MI 1
• Obtain 12-lead ECG immediately and initiate continuous cardiac monitoring to detect atrial fibrillation or other arrhythmias 1

Interpreting the Elevated NT-proBNP

Diagnostic Significance

• NT-proBNP >450 pg/mL in the acute setting indicates significant cardiac pathology that warrants the same aggressive management as established cardiovascular disease 1, 3
• In acute presentations, NT-proBNP >450 pg/mL suggests acute heart failure, acute coronary syndrome, atrial arrhythmias, or pulmonary embolism 1
• Patients with TIA accompanied by nonfocal symptoms (like dyspnea) have significantly elevated NT-proBNP levels, suggesting cardiac dysfunction as the underlying mechanism 2

Differential Considerations

The combination of neurological symptoms, dyspnea, and elevated NT-proBNP suggests:

• Cardioembolic stroke from atrial fibrillation (most likely) 1, 2
• Acute decompensated heart failure with hypoperfusion 1
• Acute coronary syndrome with cardioembolism 1
• Pulmonary embolism (though less likely with facial deviation) 1

Acute Management Algorithm

Within First Hour

• Administer aspirin 325 mg (if not contraindicated and hemorrhage ruled out) 1
• Check coagulation studies, complete blood count, comprehensive metabolic panel, troponin 1
• Measure oxygen saturation; provide supplemental oxygen if SpO2 <94% 1
• Establish IV access and maintain euvolemia 1

Anticoagulation Decision

• If atrial fibrillation is detected or high-risk cardioembolic source identified on echo, initiate anticoagulation after hemorrhage is excluded 1
• The elevated NT-proBNP increases likelihood of detecting atrial fibrillation or structural cardiac abnormality requiring anticoagulation 2

Heart Failure Management (if confirmed)

• If echocardiography confirms reduced ejection fraction with NT-proBNP >450 pg/mL, this represents acute decompensated heart failure requiring:
  • Diuretics for volume overload (given dyspnea) 1
  • ACE inhibitor or ARB initiation once stabilized 1
  • Beta-blocker after acute phase 1

Critical Pitfalls to Avoid

Do Not Dismiss the Resolved Symptoms

• Transient neurological symptoms with elevated NT-proBNP carry the same stroke risk as persistent symptoms and require full workup 2
• The resolution of slurred speech does not reduce urgency - this is a high-risk TIA pattern 1

Do Not Attribute Everything to Heart Failure

• While elevated NT-proBNP suggests cardiac dysfunction, the focal neurological findings (facial deviation) indicate stroke/TIA requiring specific stroke management 1, 2
• Both conditions may coexist and both require treatment 1, 2

Do Not Delay Echocardiography

• Echocardiography must be performed within 24 hours in acute presentations with elevated NT-proBNP to identify treatable cardiac sources of embolism 1
• Waiting for outpatient echo is inappropriate given the acute neurological event 1

Risk Stratification

High-Risk Features Present

• NT-proBNP >450 pg/mL predicts 2-3 fold increased risk of cardiovascular death and recurrent events 3
• Admission NT-proBNP >180 ng/L strongly predicts death within 76 days 1
• The combination of neurological symptoms and elevated NT-proBNP identifies patients requiring intensive monitoring and aggressive secondary prevention 2

Monitoring Requirements

• Continuous cardiac telemetry for minimum 48-72 hours to detect paroxysmal atrial fibrillation 1
• Serial neurological examinations every 2-4 hours for first 24 hours 1
• Repeat NT-proBNP at discharge for prognostic assessment - levels >137 ng/L predict poor outcomes 1