In a 70‑year‑old postoperative patient with an acute ischemic stroke, when should a bedside transthoracic echocardiogram and cardiac rhythm monitoring (telemetry or outpatient event monitor) be obtained?

Timing of Echocardiography and Cardiac Rhythm Monitoring in Acute Ischemic Stroke

In a 70-year-old postoperative patient with acute ischemic stroke, obtain a bedside transthoracic echocardiogram within 24-48 hours of stroke onset and initiate continuous cardiac monitoring immediately upon presentation, continuing for at least 24-72 hours with consideration for prolonged outpatient monitoring (30-day event monitor) if no clear etiology is identified. 1

Immediate Cardiac Rhythm Monitoring (First 24-72 Hours)

Continuous cardiac monitoring should begin immediately upon stroke presentation and continue for at least the first 24 hours. 1

• Inpatient telemetry during the acute hospitalization phase detects paroxysmal atrial fibrillation not apparent on initial ECG and identifies potentially lethal early arrhythmias that may compromise cerebral perfusion. 1
• The American Heart Association guidelines explicitly state that continuation of cardiac monitoring started in the emergency department for the first 24 hours after stroke may detect intermittent atrial fibrillation and development of significant arrhythmias. 1
• Patients with large deficits and right hemispheric strokes require particularly careful cardiovascular monitoring, as they are at higher risk for myocardial ischemia, congestive heart failure, atrial fibrillation, and significant arrhythmias. 1

Extended Monitoring Beyond 24 Hours

If the initial workup (including brain imaging, vascular imaging, and 24-hour telemetry) does not identify a clear stroke etiology, prolonged cardiac monitoring is indicated. 1

• Prolonged cardiac monitoring with either 24-hour Holter monitoring or event-looped recording for several days to weeks is useful in patients with unclear etiology after initial evaluation. 1
• The Canadian Stroke Best Practice guidelines recommend prolonged ECG monitoring up to 30 days duration in selected patients for detection of paroxysmal atrial fibrillation. 1
• Randomized trials demonstrate that longer heart monitoring in patients with cryptogenic stroke results in significantly higher atrial fibrillation detection rates: 16.1% with 30-day event-triggered recording versus 3.2% with standard monitoring. 1
• An insertable cardiac monitor detected atrial fibrillation in 8.9% of patients by 6 months versus 1.4% in controls (P<0.001). 1

Timing of Echocardiography

Transthoracic echocardiography should be performed within 24-48 hours of stroke onset, or may be obtained as an outpatient after discharge in patients with otherwise normal cardiac evaluation depending on local resources. 1

When to Obtain Echo During Hospitalization

At least transthoracic echocardiography is reasonable during the acute hospitalization, especially when the patient has no cause identified by other elements of the workup. 1

• Echocardiography (at least transthoracic) should be obtained within the 23-hour observation period as part of the standard stroke protocol. 1
• The European Stroke Organisation recommends access to transthoracic and transesophageal echocardiography 7 days a week during working hours for detection of cardiac comorbidities and cardiac or aortic sources of embolism. 1
• All patients with ischemic stroke should undergo comprehensive cardiovascular risk assessment to identify those with highest likelihood of morbidity and mortality due to unrecognized coronary heart disease or presence of a cardioembolic source. 1

Specific Indications for Immediate/Urgent Echo

Transesophageal echocardiography should be considered as the initial diagnostic tool when a cardioembolic source is suspected, particularly in younger patients or those with embolic stroke patterns and normal neurovascular imaging. 1, 2

• Transesophageal echocardiography is useful in identifying left atrial thrombus, patent foramen ovale, aortic arch atherosclerosis, and valvular disease when identification of these conditions will alter management. 1
• Echocardiography should be considered for patients with suspected embolic stroke and normal neurovascular imaging, as well as no contraindications for anticoagulant therapy, particularly relevant for younger adults with stroke of unknown etiology. 1
• Transthoracic echocardiography is excellent for identifying ventricular sources such as dyskinetic ventricular wall segments, whereas transesophageal echocardiography excels at identifying atrial and aortic sources. 1

Outpatient Echo Option

Depending on local resources, outpatient echocardiography may be obtained after discharge in patients with otherwise normal cardiac evaluation. 1

• This approach is reasonable when the patient has no evidence of cardiac disease on clinical examination, ECG, and initial monitoring, and when expedited outpatient follow-up can be arranged. 1

Age-Specific Considerations for Your 70-Year-Old Patient

In patients aged 70 years and older, the diagnostic yield of echocardiography for management-changing findings is lower compared to younger patients, but testing remains reasonable when no clear stroke etiology is identified. 3

• The number needed to test for detection of cardiac source of embolism increases 10-fold from 6 in patients younger than 50 years to 62 in patients aged 70 years and older. 3
• In older patients, routine echocardiography results in a high rate of unspecific findings and should be applied selectively, targeted at specific clinical questions. 3
• However, given that this is a postoperative patient with acute stroke, echocardiography remains indicated to exclude surgical complications, cardiac dysfunction, or other treatable sources. 1

Postoperative Context: Additional Considerations

The postoperative setting increases the importance of early echocardiography to detect procedure-related complications. 1

• Following any surgical intervention, if the patient presents with hemodynamic instability and/or inadequate cardiac output, echocardiography should be performed as a first-step examination. 1
• Pericardial collection, cardiac tamponade, and myocardial dysfunction are potential postoperative complications that can be rapidly identified with bedside echocardiography. 1

Practical Algorithm for Your Patient

Immediate Actions (Within Hours of Stroke Diagnosis):

• Initiate continuous cardiac telemetry monitoring immediately 1
• Obtain 12-lead ECG 1
• Order transthoracic echocardiogram to be performed within 24-48 hours 1

First 24-72 Hours:

• Continue telemetry monitoring for at least 24 hours, extending to 72 hours if high-risk features present 1
• Perform bedside transthoracic echocardiography 1
• If transthoracic echo is non-diagnostic and cardioembolic source is suspected, consider transesophageal echocardiography 1, 2

Before Discharge:

• If no clear stroke etiology identified after initial workup (brain imaging, vascular imaging, ECG, telemetry, and echocardiography), arrange for prolonged outpatient cardiac monitoring 1
• Order 30-day event monitor or insertable cardiac monitor for detection of paroxysmal atrial fibrillation 1

Outpatient Follow-up:

• If echocardiography was deferred during hospitalization due to normal cardiac evaluation, arrange outpatient transthoracic echo within 2 weeks 1
• Review results of prolonged cardiac monitoring at neurology follow-up 1

Common Pitfalls to Avoid

Do not delay echocardiography indefinitely in patients with cryptogenic stroke, as identification of cardioembolic sources directly impacts anticoagulation decisions and secondary prevention strategies. 1

Do not assume that a normal initial 12-lead ECG and first 24 hours of telemetry exclude paroxysmal atrial fibrillation; extended monitoring significantly increases detection rates. 1

Do not rely solely on transthoracic echocardiography when transesophageal echo is indicated; transthoracic echo has limited sensitivity for detecting left atrial thrombus, patent foramen ovale, and aortic arch atherosclerosis. 1

Do not order echocardiography in all elderly stroke patients without considering the clinical context; in patients with clear large-vessel atherosclerotic stroke and known atrial fibrillation, echocardiography may not change management. 3, 4