From the Guidelines
An echocardiogram is strongly recommended after a stroke to identify potential cardiac sources of blood clots that may have caused the stroke, as it can significantly change treatment plans and guide appropriate secondary prevention strategies. This non-invasive ultrasound test examines the heart's structure and function, specifically looking for conditions like patent foramen ovale (a hole between heart chambers), atrial fibrillation, valve abnormalities, or left ventricular thrombus that could generate emboli. The test typically takes 30-45 minutes and requires no special preparation. Finding a cardiac source of stroke can lead to anticoagulation therapy with medications like apixaban (5mg twice daily) or warfarin rather than antiplatelet therapy, and identifying a patent foramen ovale might prompt consideration of closure procedures in certain patients 1.
According to the Canadian Stroke Best Practice Recommendations, echocardiography (2D or TEE) may be considered in patients where a cardiac cause of stroke is suspected, including in young adults and children who present with stroke, and when infectious endocarditis is suspected 1. Additionally, the European Association of Cardiovascular Imaging recommends the use of echocardiography in acute cardiovascular care, including in patients with suspected embolic stroke and normal neurovascular imaging 1.
Some key points to consider when deciding to perform an echocardiogram after a stroke include:
- The patient's age and presence of traditional stroke risk factors
- The presence of symptoms or signs suggestive of heart failure, myocardial ischemia/infarction, syncope, thromboembolism, infective endocarditis, or clinical evidence of structural heart disease
- The results of initial short-term ECG monitoring and the need for prolonged ECG monitoring to detect paroxysmal atrial fibrillation
- The potential benefits of anticoagulation therapy or closure procedures in certain patients
Overall, an echocardiogram is a crucial component of comprehensive post-stroke care, and its use can help guide appropriate secondary prevention strategies and improve patient outcomes 1.
From the Research
Importance of Echocardiogram After Stroke
Echocardiography is a crucial diagnostic tool for patients who have experienced a stroke, as it helps identify potential cardiac sources of embolism. The following points highlight the significance of getting an echocardiogram after a stroke:
- Echocardiography can detect cardioembolic sources, which are responsible for 15-40% of all ischemic strokes 2, 3.
- Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are cornerstones in the detection of cardioembolic sources and provide fundamental information about the embolic risk and most suitable treatment of these patients 2.
- The most common cardioembolic sources include left atrial appendage thrombosis during atrial fibrillation, vegetations in infective endocarditis, cardiac masses, atherosclerotic plaques, and passageways within the heart serving as conduits for paradoxical embolization 2.
Diagnostic Yield of Echocardiography
The diagnostic yield of echocardiography in patients with stroke varies depending on the patient's age and clinical presentation. Key findings include:
- A potential cardiac source of embolism was found in 18% of patients with ischemic stroke or transient ischemic attack 4.
- The most frequent potential causes of cardiac embolism included atrial fibrillation and patent foramen ovale 4.
- Echocardiography has a higher diagnostic yield in younger patients, with numbers needed to test for detection of cardiac source of embolism increasing 10-fold from 6 in patients younger than 50 years to 62 in patients aged 70 years and older 4.
Role of Echocardiography in Clinical Practice
Echocardiography plays a vital role in the clinical practice of managing patients with stroke. The following points emphasize its importance:
- Echocardiography is a widely available, inexpensive, and safe diagnostic tool that is almost free from contraindication 2.
- TTE and TEE are essential for identifying clinically actionable findings for secondary stroke prevention, including cardiac thrombus, patent foramen ovale, atrial myxoma, or valvular vegetation 5.
- Echocardiography should be performed routinely in patients with cryptogenic stroke, as it can detect patent foramen ovale and other cardiac sources of embolism 5, 6.