This Article Abstract Full Text (PDF) All Versions of this Article: 36/7/1565    most recent 01.STR.0000170636.08554.49v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by de Abreu, T. T. Articles by Correia, J. Search for Related Content PubMed PubMed Citation Articles by de Abreu, T. T. Articles by Correia, J. Related Collections Echocardiography Acute Cerebral Infarction Anticoagulants

(Stroke. 2005;36:1565.)
© 2005 American Heart Association, Inc.

Research Reports

Therapy Implications of Transthoracic Echocardiography in Acute Ischemic Stroke Patients

Tiago Tribolet de Abreu, MD; Sónia Mateus José Correia, MD

From the Cardiac and Neurologic Ultrassonography Laboratory, Hospital do Espírito Santo-Évora, Évora, Portugal.

Correspondence to Tiago Tribolet de Abreu, Cardiac and Neurologic Ultrassonography Laboratory, Hospital do Espírito Santo-Évora, Rua Dr. Celestino David, n° 32, 7000-852 Évora, Portugal. E-mail ttabreu{at}clix.pt

	Abstract

Top Abstract Introduction Materials and Methods Results Discussion References

 
Background and Purpose— Stroke is the third leading cause of death in most Western countries. Cardioembolism might be responsible for 15% to 20% of ischemic strokes. Although atrial fibrillation can be diagnosed by electrocardiography, the remaining causes of cardioembolic stroke are diagnosed by echocardiography. Recent recommendations on the management of acute ischemic stroke fail to consider echocardiography as an essential test in all patients.

Methods— We conducted a prospective observational study, performing transthoracic echocardiography on all patients admitted in our hospital with ischemic stroke, in sinus rhythm, from January 7, 2002, to October 16, 2003. Findings compatible with heart diseases that would indicate anticoagulation as beneficial were identified.

Results— Of the 853 patients admitted with ischemic stroke, transthoracic echocardiography was performed on 846 (99.2%). Of the 435 patients with ischemic stroke, in sinus rhythm, 37.2% had findings indicating anticoagulation as beneficial: dilated cardiopathy (19.1%), previous anterior wall myocardial infarction (6.2%), left ventricular systolic dysfunction with an ejection fraction <35% (3.7%), mitral valve stenosis with enlarged left atria (1.6%), intracardiac masses (0.5%), valvular prosthesis (0.2%), and >1 abnormality (5.5%).

Conclusions— In our study, transthoracic echocardiography had therapy implications in 37.2% of ischemic stroke patients in sinus rhythm. Transthoracic echocardiography should be considered an essential test in all ischemic stroke patients in sinus rhythm.

Key Words: anticoagulants • echocardiography • stroke, ischemic

	Introduction

Top Abstract Introduction Materials and Methods Results Discussion References

 
Stroke is the third leading cause of death in most Western countries.¹ Stroke can be ischemic (85%) or hemorrhagic (10% to 15%),^2,3 and ischemic stroke can be classified, according to etiology,⁴ as: (1) large vessel atherosclerosis, (2) cardioembolic, (3) small vessel atherosclerosis (lacunes), (4) other determined etiology, or (5) undetermined etiology.

Embolism accounts for 15% to 20% of all strokes.⁵ Several heart diseases are potentially embolic,^5–7 and some indicate anticoagulation as beneficial^8–11 and should therefore be identified.

Although atrial fibrillation, responsible for 50% of cardioembolic strokes,¹¹ can be diagnosed by an ECG, echocardiography is an important test in the diagnosis of the remaining embolic heart diseases. Nevertheless, the role of echocardiography in the management of patients with acute stroke is not clear; recent recommendations on the management of acute stroke^12,13 fail to consider echocardiography as an essential test in all patients.

The goal of the current study was to determine the prevalence of heart disease that would have therapy implications (anticoagulation) in acute ischemic stroke patients without atrial fibrillation.

	Materials and Methods

Top Abstract Introduction Materials and Methods Results Discussion References

 
We conducted a prospective observational study from January 7, 2002, to October 16, 2003. The study was approved by our hospital ethics committee. Informed consent was obtained from all patients.

Patients
All patients sent to our unit for transthoracic echocardiography with an acute ischemic stroke in sinus rhythm were included in the study.

Acute ischemic stroke was defined as an acute neurological deficit persisting for >24 hours, with primary cerebral hemorrhage or nonvascular causes excluded by computed tomographic brain scan within 24 hours of presentation.¹⁴ Sinus rhythm was defined at the time of the performance of the echocardiogram (as evaluated by the cardiac monitoring of the patient) or previously (as evaluated by previously performed electrocardiograms).

Heart diseases that indicate anticoagulation as beneficial,^8–11 were defined as: mitral valve stenosis with an enlarged (>55 mm) left atria, valve prosthesis, left ventricular systolic dysfunction (with an estimated ejection fraction <35%), dilated cardiopathy, previous myocardial infarction (with left ventricular wall dyskinesis), left atria, or left ventricle masses.

Echocardiography
The authors performed all echocardiograms using a 2.5-MHz transducer for M-mode, 2D, and Doppler transthoracic echocardiography. All exams were performed and interpreted by the recommendations of the American Echocardiography Society.¹⁵

	Results

Top Abstract Introduction Materials and Methods Results Discussion References

 
During the study, 846 patients with acute ischemic stroke were sent to our unit for transthoracic echocardiography. A total of 435 of those patients were in sinus rhythm.

The demographic characteristics of the study patients are depicted in Table 1. All patients were white.

View this table: [in this window] [in a new window]   TABLE 1. Demographic Characteristics of the Study Patients (n=435)

The echocardiography findings suggested a heart disease indicating a benefit of anticoagulation in 162 (37.2%) patients. The echocardiography findings are summarized in Table 2.

View this table: [in this window] [in a new window]   TABLE 2. Echocardiography Findings (n=435)

	Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
In our study population, 37.2% of patients with acute ischemic stroke, in sinus rhythm, had findings on transthoracic echocardiography that had a therapy implication: a benefit of anticoagulation.

During the study period, 853 patients were admitted to our hospital with acute ischemic stroke, of whom 846 patients (99.2%) were sent to our unit for transthoracic echocardiography. These facts reduce the possibility of bias of the study population.

Some of the echocardiography findings indicating anticoagulation as beneficial might have been diagnosed without echocardiography: valve prosthesis and previous anterior wall myocardial infarction. Although this is true for valve prosthesis, we believe that the inclusion of the only patient with this condition does not significantly change the results of our study. The history and the ECG of the patient can diagnose previous anterior wall myocardial infarction. Nevertheless, only transthoracic echocardiography can determine the degree of anterior wall motion abnormalities. The remaining findings, although possible to suspect on clinical grounds, needed transthoracic echocardiography for confirmation.

In conclusion, in our study population, the performance of transthoracic echocardiography on acute ischemic stroke patients without atrial fibrillation had therapy implications in 37.2%. Although these results must be confirmed in other ischemic stroke populations, we believe these results support the transthoracic echocardiogram as a compulsory examination on all acute ischemic stroke patients.

	Acknowledgments

 
Thanks to Marie Helen Curry for reviewing this manuscript.

Received January 14, 2005; revision received April 11, 2005; accepted April 27, 2005.

	References

Top Abstract Introduction Materials and Methods Results Discussion References

 

1. Bogousslavsky J, Kaste M, Olsen TS, Hacke W, Orgogozo JM. Risk factors and stroke prevention. Cerebrovasc Dis. 2000; 10 (suppl 3): 12–21.
2. Qureshi AI, Tuhrim S, Broderick JP, Batjer HH, Hondo H, Hanley DF. Spontaneous intracerebral hemorrhage. N Engl J Med. 2001; 344: 1450–1460.[Free Full Text]
3. European Stroke Initiative. Stroke prevention by the practitioner. Cerebrovasc Dis. 1999; 9 (suppl 4): 1–68.
4. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE III. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993; 24: 35–41.[Abstract/Free Full Text]
5. Semple PF, Sacco RL. An Atlas of Stroke. 2nd ed. London, UK: The Parthenon Publishing Group; 1999: 24.
6. Kistler JP. The risk of embolic stroke: another piece of the puzzle. N Engl J Med. 1994; 331: 1517–1519.[Free Full Text]
7. Amarenco P, Cohen A, Tzourio C, Bertrand B, Hommel M, Besson G, Chauvel C, Touboul PJ, Bousser MG. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med. 1994; 331: 1474–1479.[Abstract/Free Full Text]
8. Majerus PW, Broze GJ, Miletich JP, Tollejseu DM. Anticoagulant, thrombolytic and antiplatelet drugs. In: Hardman JG, Limbird LE, Molinoff PB, Ruddon RW, Gildman AG, eds. Goodman and Gilman’s the Pharmacological Basis of Therapeutics. 9th ed. New York: McGraw-Hill; 1996: 1341–1359.
9. Mohr JP, Thompson JL, Lazar RM, Levin B, Sacco RL, Furie KL, Kistler JP, Albers GW, Pettigrew LC, Adams HP Jr, Jackson CM, Pullicino P; Warfarin-Aspirin Recurrent Stroke Study Group. A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med. 2001; 345: 1444–1451.[Abstract/Free Full Text]
10. Powers JW. Oral anticoagulant therapy for the prevention of stroke. N Engl J Med. 2001; 345: 1493–1495.[Free Full Text]
11. Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. Antithrombotic and thrombolytic therapy for ischemic stroke. Chest. 2001; 119: 300S–320S.[CrossRef][Medline] [Order article via Infotrieve]
12. Adams HP Jr, Adams RJ, Brott T, del Zoppo GJ, Furlan A, Goldstein LB, Grubb RL, Higashida R, Kidwell C, Kwiatkowski TG, Marler JR, Hademenos GJ; Stroke Council of the American Stroke Association. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. Stroke. 2003; 34: 1056–1083.[Free Full Text]
13. Hack W, Kaste M, Bogousslavsky J, Brainin M, Chamorro A, Lees K, Leys D, Kwiecinski H, Toni P, Langhorne P, Diener C, Hennerici M, Ferro J, Sivenius J, Gunnar N, Bath P, Olsen TS, Gugging M; European Stroke Initiative Executive Committee and the EUSI Writing Committee. European Stroke Initiative Recommendations for Stroke Management: update 2003. Cerebrovasc Dis. 2003; 16: 311–337.[CrossRef][Medline] [Order article via Infotrieve]
14. Jones EF, Kalman JM, Calafiore P, Tonkin AM, Donnan GA. Proximal aortic atheroma: an independent risk factor for cerebral ischemia. Stroke. 1995; 26: 218–224.[Medline] [Order article via Infotrieve]
15. Henry WL, DeMaria A, Gramiak R, King DL, Kisslo JA, Popp RL, Sahn DJ, Schiller NB, Tajik A, Teichholz LE, Weyman AE. Report of the American Society of Echocardiography Committee on Nomenclature and Standards in Two-Dimensional Echocardiography. Circulation. 1980; 62: 212–215.[Free Full Text]

This article has been cited by other articles:

				T. G. Phan, V. Srikanth, D. C. Reutens, T. T. de Abreu, S. Mateus, J. Correia, and M. J. Alberts Therapeutic Implications for Routine Transthoracic Echocardiography in Acute Ischemic Stroke Patients Stroke, January 1, 2006; 37(1): 11 - 12. [Full Text] [PDF]

				C. A. Molina Imaging the Clot: Does Clot Appearance Predict the Efficacy of Thrombolysis? Stroke, November 1, 2005; 36(11): 2333 - 2334. [Full Text] [PDF]

This Article Abstract Full Text (PDF) All Versions of this Article: 36/7/1565    most recent 01.STR.0000170636.08554.49v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by de Abreu, T. T. Articles by Correia, J. Search for Related Content PubMed PubMed Citation Articles by de Abreu, T. T. Articles by Correia, J. Related Collections Echocardiography Acute Cerebral Infarction Anticoagulants