PURPOSE: Cerebrovascular accidents constitute a common indication for echocardiography. ACC/AHA guidelines for the clinical application of echocardiography have been available since 2003. In view of the recent concerns about the uncontrolled growth in cardiac imaging, we investigated the appropriateness of use of echocardiography in cerebrovascular ischemia in a tertiary care teaching hospital using the ACC/AHA guidelines.
METHODS: 204 consecutive patients (mean age 65 + 11 years, 198 men) with history of transient ischemic attacks (TIA) [94(46%)], and cerebrovascular accidents (CVA) [110(54%)] were screened for the presence of potential cardiac and aortic sources of embolism by either transesophageal [TEE: 109 (53%)] or transthoracic [TTE: 95 (47%)] echocardiography. Risk factors were hypertension (83%), diabetes (40%), smoking (53%), dyslipidemia (61%), and atrial fibrillation (6%).
RESULTS: Applying ACC/AHA guidelines in 204 patients, 120(59%) had class I, 23 (11%) had class IIa, 29(14%) had class IIb, and 32 (16%) had class III indication for echocardiogram. Among 95 patients that underwent TTE, the frequency of abnormal findings was as follows: 7(7%) microcavitation, 7(7%) low ejection fraction, 1 (1%) LV aneurysm, 1(1%) LV thrombus, and 1(1%) ASD. Among 109 patients that underwent TEE, the frequency of abnormal findings was as follows: 83 (76%) aortic atherosclerosis, 19(17%) PFO, 8(7%) atrial septal aneurysm, 21 (19%) microcavitation, 7(6%) low ejection fraction, 1(1%) LV thrombus, 1(1%) LV aneurysm, and 1 (1%) vegetation. The management was changed based on echo findings (TEE: 25, TTE: 2) in only 27 patients (13%), all with either class I or class IIa indication.
CONCLUSION: TEE identified potentially treatable cardio-embolic sources that changed management more often than TTE (class I and IIa). On applying the current ACC/AHA guidelines 16% of echocardiograms were categorized as class III.
CLINICAL IMPLICATIONS: Prior screening for carotid disease and assessment for indications for and contraindications to anticoagulants in patients with TIA/CVA could reduce the frequency of class III studies and reduce costs. More awareness is needed of ACC/AHA indications for echo in cerebrovascular patients.
DISCLOSURE: Dipesh Pokharel, None.