How do you determine if a stroke in an adult patient with a history of ischemic stroke and potential comorbidities such as hypertension, diabetes, or atrial fibrillation is cardioembolic or not?

Determining Cardioembolic Stroke Mechanism

To determine if a stroke is cardioembolic, perform a 12-lead ECG immediately to detect atrial fibrillation, obtain cardiac monitoring for at least 24 hours, and consider prolonged ECG monitoring up to 30 days if initial studies are negative but cardioembolic mechanism is suspected, along with echocardiography when the stroke mechanism remains unidentified. 1

Immediate Cardiac Evaluation

Essential Initial Tests

• Perform a 12-lead ECG on all stroke patients immediately to detect atrial fibrillation, the most important cardioembolic source that increases stroke risk 5-fold compared to hypertension's 2-fold increase 1
• Obtain cardiac enzyme tests (troponin preferred) as acute myocardial infarction can lead to stroke, and stroke can cause myocardial ischemia 1
• Conduct cardiovascular examination to identify structural heart disease, heart failure, or valvular abnormalities 1

Continuous Cardiac Monitoring

• Institute continuous ECG monitoring for at least the first 24 hours after acute stroke to screen for serious cardiac arrhythmias and detect paroxysmal atrial fibrillation 1
• Cardiac complications account for 2-6% of mortality within the first 3 months, with highest risk in the first 2 weeks 1

Extended Cardiac Investigation

Prolonged Rhythm Monitoring

• When initial ECG and 24-48 hour monitoring do not show atrial fibrillation but cardioembolic mechanism is suspected, perform prolonged ECG monitoring up to 30 days duration in selected patients for detection of paroxysmal atrial fibrillation 1
• This is particularly important as atrial fibrillation may be paroxysmal and not detected on admission ECG 1

Echocardiography

• Consider echocardiogram when the stroke mechanism has not been identified after initial evaluation 1
• Transthoracic and transesophageal echocardiography can disclose structural heart diseases, intracardiac thrombus, valvular abnormalities, and left atrial appendage abnormalities 2, 3

Clinical Features Suggesting Cardioembolic Origin

High-Probability Clinical Presentations

• Sudden onset to maximal deficit without gradual progression 3
• Decreased level of consciousness at onset 3
• Wernicke's aphasia or global aphasia without hemiparesis 3
• Valsalva maneuver at time of stroke onset 3
• Co-occurrence of cerebral and systemic emboli 3

Features Making Cardioembolic Origin Unlikely

• Lacunar clinical presentations and especially multiple lacunar infarcts make cardioembolic origin unlikely 3

High-Risk Cardioembolic Conditions to Identify

Most Common Sources

• Atrial fibrillation (most common, 5-fold increased stroke risk) 1, 2, 4
• Recent myocardial infarction 3
• Mechanical prosthetic valve 3
• Dilated cardiomyopathy 3
• Mitral rheumatic stenosis 3
• Heart failure (predictor of cardiac complications) 1

Additional Risk Markers

• History of heart failure, diabetes, elevated creatinine, severe stroke, and long-QT segment or ventricular extrasystoles on ECG predict cardiac complications 1

Vascular Imaging to Exclude Non-Cardioembolic Mechanisms

Essential Vascular Studies

• Perform CT angiography from aortic arch to vertex to assess both extracranial and intracranial circulation and identify alternative stroke etiologies such as large vessel atherosclerosis 1, 5, 6
• Obtain extracranial vascular imaging to identify carotid stenosis that would suggest atherosclerotic rather than cardioembolic mechanism 1

Important Clinical Pitfalls

Common Diagnostic Errors

• Do not assume all strokes in atrial fibrillation patients are cardioembolic - a substantial number have non-cardioembolic mechanisms including complex aortic plaque, significant carotid stenosis, or intracranial arterial stenosis 7
• Non-cardioembolic risk factors are associated with age, hypertension, diabetes, and coronary artery calcium score even in patients with atrial fibrillation 7
• Absence of atrial fibrillation on initial ECG does not exclude cardioembolic mechanism - prolonged monitoring may be necessary 1

Timing Considerations

• Cardioembolic stroke accounts for 20-30% of ischemic strokes and is associated with worse outcomes and higher in-hospital mortality (27.3%) compared to other stroke subtypes 2, 4, 3
• Patients with early embolic recurrence within the first 7 days have 77% in-hospital mortality 3