What is the initial cardiovascular workup for an adult stroke patient with potential history of hypertension, diabetes, and hyperlipidemia?

Initial Cardiovascular Workup for Adult Stroke Patients

The initial cardiovascular workup for an adult stroke patient with hypertension, diabetes, and hyperlipidemia should include urgent vascular imaging (CT angiography, MR angiography, or carotid ultrasound within 24-48 hours), continuous cardiac monitoring for at least 24 hours to detect atrial fibrillation, ECG, echocardiography to evaluate for cardioembolic sources, and comprehensive laboratory assessment including lipid panel, glucose, complete blood count, metabolic panel, and coagulation studies. 1, 2

Immediate Diagnostic Imaging

• Obtain CT angiography or MR angiography of the head and neck (or carotid ultrasound) within 24-48 hours to identify ipsilateral carotid stenosis ≥70%, which would require urgent surgical intervention if present 1, 2
• Non-contrast CT head should be obtained immediately to differentiate ischemic from hemorrhagic stroke 2
• If carotid stenosis ≥70% is identified, carotid endarterectomy should be performed within 14 days if surgical team morbidity/mortality risk is <6% 1

Cardiac Evaluation

• Perform continuous cardiac monitoring for at least 24 hours to detect paroxysmal atrial fibrillation, which affects 5% of those ≥70 years and increases stroke risk 3- to 4-fold 3, 1, 2
• Obtain ECG immediately to identify cardioembolic sources and evaluate for arrhythmias 2, 4
• Complete echocardiography to evaluate for cardioembolic sources, particularly if atrial fibrillation or valvular disease is suspected 1, 2, 4

The cardiac workup is critical because atrial fibrillation alone is associated with a 3- to 4-fold increased risk of stroke, and approximately 60,000 strokes occur annually among Americans with this dysrhythmia 3. Strokes associated with atrial fibrillation are especially large and disabling 3.

Laboratory Assessment

• Obtain comprehensive laboratory studies within 10 minutes of ED arrival including: 2

  • Complete blood count
  • Comprehensive metabolic panel (to assess renal function given diabetes)
  • Coagulation studies (PT/INR)
  • Lipid panel (total cholesterol, LDL, HDL, triglycerides)
  • Capillary blood glucose immediately (hypoglycemia can mimic stroke) 2
  • Creatine kinase 4

• Check HbA1c to assess long-term glycemic control, as diabetes increases stroke risk 1.8- to 6-fold 3

Risk Factor Documentation

Given the patient's history of hypertension, diabetes, and hyperlipidemia, document the following specific parameters:

• Blood pressure measurements: Current BP and assess for adequacy of control (target <140/90 mmHg in diabetics, though <130/80 mmHg is increasingly recommended) 3, 1
• Lipid levels: Particularly LDL cholesterol, as target should be <70 mg/dL or even <40 mg/dL for secondary prevention 1
• Glycemic control: Current glucose and HbA1c, with target HbA1c of 7.0-7.5% in patients with established cardiovascular disease 1, 5
• Smoking status: Document current or past tobacco use, as it is a major modifiable risk factor 3, 4, 6

Additional Cardiovascular Risk Assessment

• Assess for additional atherosclerotic disease in other vascular territories (coronary, peripheral), as atherosclerosis is the most common underlying cause of ischemic stroke 3
• Consider inflammatory markers (C-reactive protein) if etiology remains unclear, as elevated CRP increases risk of thromboembolic stroke 6
• Evaluate for sleep-disordered breathing, particularly if patient has obesity (BMI ≥30) and drug-resistant hypertension, as this is an emerging risk factor 3, 6

Critical Pitfalls to Avoid

• Do not delay imaging – "time is brain" and every minute counts for determining stroke mechanism and treatment eligibility 2
• Do not miss paroxysmal atrial fibrillation – requires at least 24 hours of continuous monitoring, not just a single ECG, as rhythm control does not reduce stroke rates and anticoagulation is the mainstay of prevention 3, 2
• Do not overlook hypercoagulable state evaluation if indicated by patient age and clinical context, particularly in younger patients or those with unclear etiology 1

The evidence strongly supports that among U.S. adults with hypertension, 27.2% have diabetes and 63.2% have hypercholesterolemia, making comprehensive cardiovascular assessment essential 3. Furthermore, fewer than 50% of stroke patients reliably have their risk factors assessed, treated, or controlled, highlighting the critical importance of thorough initial workup 3, 7.