Readjustment of antithrombotic therapy in stroke-patients owing to transesophageal echocardiography findings
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Abstract
Objectives: Cardioembolic etiology is a frequent source of ischemic stroke. Echocardiogram is the mainstay of cardioembolic source detection with regard to plan secondary stroke management, however it remains unclear how often clinically actionable findings are provided hereby. In addition, it is uncertain whether echocardiography should be performed transthoracic or transesophageal (TEE). In a monocenter study, we evaluated the frequency of pathological findings from TEE evaluation in patients with ischemic stroke with suspected cardioembolic and cryptogenic source and determined whether there was an associated adjustment in the prescribed administration of antithrombotic therapy.
Materials and Methods: Over a 21-month period (2012-2013), we enrolled 143 patients in a prospective monocenter study (mean age ± standard deviation, 70 ± 12 years; females, 44.1%) who were admitted to the Department of Neurology at the University of Lübeck due to ischemic stroke and who underwent TEE due to supposed cardiac embolism. We assessed the presence of atrial fibrillation; days from admission to TEE; and TEE findings, including atrial septal aneurysm, thrombogenic aortic arch, valve failure, presence of left atrial thrombus, and patent foramen ovale. Demografic information and medical history were drawn from patient records and the hospital information system.
Results: On average, TEE was performed 4 days after admission to the hospital. Left atrial thrombus was detected in 3 patients (2.1%), patent foramen ovale (PFO) in 27 (18.9%), atrial septum aneurysm in 17 (11.9%), and thrombogenic aortic arch in 29 (20.3%). Findings from TEE were commonly associated with therapeutic adjustment; antiplatelet therapy increased from 30.1% to 80.4%, oral anticoagulation therapy increased from 2.8% to 27.3%.
Conclusion: Findings from TEE for the evaluation of ischemic stroke lead to frequent adjustment of prior antithrombotic therapy, antiplatelet as well as anticoagulation.
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Bogousslavsky J, Kaste M, Skyhoj Olsen T, Hacke W, Orgogozo JM. Risk factors and stroke prevention. European stroke initiative (eusi). Cerebrovasc Dis. 2000;10 Suppl 3:12-21. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/10940666
Grau AJ, Weimar C, Buggle F, Heinrich A, Goertler M, et al. Risk factors, outcome, and treatment in subtypes of ischemic stroke: The german stroke data bank. Stroke 2001; 32: 2559-2566. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/11692017
Grau AJ, Eicke M, Biegler MK, Faldum A, Bamberg C, et al. Quality monitoring of acute stroke care in rhineland-palatinate, germany, 2001-2006. Stroke. 2010; 41: 1495-1500. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/20522811
Ferro JM. Cardioembolic stroke: An update. Lancet Neurol. 2003; 2: 177-188. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/12849239
Sacco RL, Adams R, Albers G, Alberts MJ, Benavente O, et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: A statement for healthcare professionals from the american heart association/american stroke association council on stroke: Co-sponsored by the council on cardiovascular radiology and intervention: The american academy of neurology affirms the value of this guideline. Stroke. 2006; 37: 577-617. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/16432246
Goldstein LB, Adams R, Alberts MJ, Appel LJ, Brass LM, et al. Primary prevention of ischemic stroke: A guideline from the american heart association/american stroke association stroke council: Cosponsored by the atherosclerotic peripheral vascular disease interdisciplinary working group; cardiovascular nursing council; clinical cardiology council; nutrition, physical activity, and metabolism council; and the quality of care and outcomes research interdisciplinary working group: The american academy of neurology affirms the value of this guideline. Stroke. 2006; 37: 1583-1633. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/16675728
Kittner SJ, Sharkness CM, Price TR, Plotnick GD, Dambrosia JM, et al. Infarcts with a cardiac source of embolism in the nincds stroke data bank: Historical features. Neurology. 1990; 40: 281-284. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/2300250
Hart RG. Cardiogenic embolism to the brain. Lancet. 1992; 339: 589-594. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/3510609
Ahmed N, Audebert H, Turc G, Cordonnier C, Christensen H, et al. Consensus statements and recommendations from the eso- karolinska stroke update conference, stockholm 11–13 November 2018. Eur Stroke J. 2019.
Pepi M, Evangelista A, Nihoyannopoulos P, Flachskampf FA, Athanassopoulos G, et al. Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism: European association of echocardiography (eae) (a registered branch of the esc). Eur J Echocardiogr. 2010; 11: 461-476. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/20702884
Yu EH, Lungu C, Kanner RM, Libman RB. The use of diagnostic tests in patients with acute ischemic stroke. Journal of stroke and cerebrovascular diseases: The official journal of National Stroke Association. 2009; 18: 178-184.
Katsanos AH, Giannopoulos S, Frogoudaki A, Vrettou AR, Ikonomidis I, et al. The diagnostic yield of transesophageal echocardiography in patients with cryptogenic cerebral ischaemia: A meta-analysis. Eur J Neurol. 2016; 23: 569-579. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/26918744
Zhang L, Harrison JK, Goldstein LB. Echocardiography for the detection of cardiac sources of embolism in patients with stroke or transient ischemic attack. J Stroke Cerebrovasc Dis. 2012; 21: 577-582. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/21367623
Wolber T, Maeder M, Atefy R, Bluzaite I, Blank R, et al. Should routine echocardiography be performed in all patients with stroke? J Stroke Cerebrovasc Dis. 2007; 16: 1-7. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/17689384
Sondergaard L, Kasner SE, Rhodes JF, Andersen G, Iversen HK, et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med. 2017; 377: 1033-1042. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/28902580
Saver JL, Carroll JD, Thaler DE, Smalling RW, MacDonald LA, et al. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med. 2017; 377: 1022-1032. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/28902590
Mas JL, Derumeaux G, Guillon B, Massardier E, Hosseini H, et al. Patent foramen ovale closure or anticoagulation vs. Antiplatelets after stroke. N Engl J Med. 2017; 377: 1011-1021. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/28902593
Saric M, Armour AC, Arnaout MS, Chaudhry FA, Grimm RA, et al. Guidelines for the use of echocardiography in the evaluation of a cardiac source of embolism. J Am Soc Echocardiogr. 2016; 29: 1-42. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/26765302
Vitebskiy S, Fox K, Hoit BD. Routine transesophageal echocardiography for the evaluation of cerebral emboli in elderly patients. Echocardiography. 2005; 22: 770-774. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/16194171
de Bruijn SF, Agema WR, Lammers GJ, van der Wall EE, Wolterbeek R, et al. Transesophageal echocardiography is superior to transthoracic echocardiography in management of patients of any age with transient ischemic attack or stroke. Stroke. 2006; 37: 2531-2534. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/16946152
Leung DY, Black IW, Cranney GB, Walsh WF, Grimm RA, et al. Selection of patients for transesophageal echocardiography after stroke and systemic embolic events. Role of transthoracic echocardiography. Stroke. 1995; 26: 1820-1824. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/7570732
Harloff A, Handke M, Reinhard M, Geibel A, Hetzel A. Therapeutic strategies after examination by transesophageal echocardiography in 503 patients with ischemic stroke. Stroke. 2006; 37: 859-864. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/16439702
Cho HJ, Choi HY, Kim YD, Nam HS, Han SW, et al. Transoesophageal echocardiography in patients with acute stroke with sinus rhythm and no cardiac disease history. J Neurol Neurosurg Psychiatry. 2010; 81: 412-415. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/19965855
McGrath ER, Paikin JS, Motlagh B, Salehian O, Kapral MK, et al. Transesophageal echocardiography in patients with cryptogenic ischemic stroke: A systematic review. Am Heart J. 2014; 168: 706-712. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/25440799
Haeusler KG, Wollboldt C, Bentheim LZ, Herm J, Jager S, et al. Feasibility and diagnostic value of cardiovascular magnetic resonance imaging after acute ischemic stroke of undetermined origin. Stroke. 2017; 48: 1241-1247. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/28411261
Galougahi KK, Stewart T, Choong CY, Storey CE, Yates M, et al. The utility of transoesophageal echocardiography to determine management in suspected embolic stroke. Intern Med J. 2010; 40: 813-818. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/19849751
Ahmad O, Ahmad KE, Dear KB, Harvey I, Hughes A, et al. Echocardiography in the detection of cardioembolism in a stroke population. J Clin Neurosci. 2010; 17: 561-565. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/20207149
Pallesen LP, Ragaller M, Kepplinger J, Barlinn K, Zerna C, et al. Diagnostic impact of transesophageal echocardiography in patients with acute cerebral ischemia. Echocardiography. 2016; 33: 555-561. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/27103483
Censori B, Colombo F, Valsecchi MG, Clivati L, Zonca A, et al. Early transoesophageal echocardiography in cryptogenic and lacunar stroke and transient ischaemic attack. J Neurol Neurosurg Psychiatry. 1998; 64: 624-627. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/9598678
Amarenco P, Duyckaerts C, Tzourio C, Henin D, Bousser MG, et al. The prevalence of ulcerated plaques in the aortic arch in patients with stroke. N Engl J Med. 1992; 326: 221-225. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/1727976
Menon BK, Coulter JI, Bal S, Godzwon C, Weeks S, et al. Acute ischaemic stroke or transient ischaemic attack and the need for inpatient echocardiography. Postgrad Med J. 2014; 90: 434-438. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/24920609
Nakanishi K, Homma S. Role of echocardiography in patients with stroke. J Cardiol. 2016; 68: 91-99. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/27256218
Fralick M, Goldberg N, Rohailla S, Guo Y, Burke MJ, et al. Value of routine echocardiography in the management of stroke. CMAJ. 2019; 191: E853-E859. PubMed: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6682481/
Cheitlin MD, Alpert JS, Armstrong WF, Aurigemma GP, Beller GA, et al. Acc/aha guidelines for the clinical application of echocardiography. A report of the american college of cardiology/american heart association task force on practice guidelines (committee on clinical application of echocardiography). Developed in collaboration with the american society of echocardiography. Circulation. 1997; 95: 1686-1744. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/9118558
Mas JL, Arquizan C, Lamy C, Zuber M, Cabanes L, et al. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med. 2001; 345: 1740-1746. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/11742048
Kuijpers T, Spencer FA, Siemieniuk RAC, Vandvik PO, Otto CM, et al. Patent foramen ovale closure, antiplatelet therapy or anticoagulation therapy alone for management of cryptogenic stroke? A clinical practice guideline. BMJ. 2018; 362: k2515. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/30045912
Mir H, Siemieniuk RAC, Ge L, Foroutan F, Fralick M, et al. Patent foramen ovale closure, antiplatelet therapy or anticoagulation in patients with patent foramen ovale and cryptogenic stroke: A systematic review and network meta-analysis incorporating complementary external evidence. BMJ Open. 2018; 8: e023761. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/30121619
Di Tullio M, Sacco RL, Gopal A, Mohr JP, Homma S. Patent foramen ovale as a risk factor for cryptogenic stroke. Ann Intern Med. 1992; 117: 461-465. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/1503349
Katsanos AH, Bhole R, Frogoudaki A, Giannopoulos S, Goyal N, et al. The value of transesophageal echocardiography for embolic strokes of undetermined source. Neurology. 2016; 87: 988-995. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/27488602
Capmany RP, Ibanez MO, Pesquer XJ. Complex atheromatosis of the aortic arch in cerebral infarction. Curr Cardiol Rev. 2010; 6: 184-193. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/21804777
Meissner I, Khandheria BK, Sheps SG, Schwartz GL, Wiebers DO, et al. Atherosclerosis of the aorta: Risk factor, risk marker, or innocent bystander? A prospective population-based transesophageal echocardiography study. J Am Coll Cardiol. 2004; 44: 1018-1024. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/15337213
Mojadidi MK, Winoker JS, Roberts SC, Msaouel P, Zaman MO, et al. Accuracy of conventional transthoracic echocardiography for the diagnosis of intracardiac right-to-left shunt: A meta-analysis of prospective studies. Echocardiography. 2014; 31: 1036-1048. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/24689727
Amarenco P, Cohen A, Tzourio C, Bertrand B, Hommel M, et al. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med. 1994; 331: 1474-1479. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/7969297
French Study of Aortic Plaques in Stroke G, Amarenco P, Cohen A, Hommel M, Moulin T, Leys D, et al. Atherosclerotic disease of the aortic arch as a risk factor for recurrent ischemic stroke. N Engl J Med. 1996; 334: 1216-1221. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/8606716
Pujadas R, Arboix A, Anguera N, Oliveres M, Massons J, et al. [role of complex aortic atheroma plaques in the recurrence of unexplained cerebral infarction]. Rev Esp Cardiol. 2005; 58: 34-40. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/15680129
Fernandez-Ortiz A, Badimon JJ, Falk E, Fuster V, Meyer B, et al. Characterization of the relative thrombogenicity of atherosclerotic plaque components: Implications for consequences of plaque rupture. J Am Coll Cardiol. 1994; 23: 1562-1569. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/8195515
Davila-Roman VG, Barzilai B, Wareing TH, Murphy SF, Schechtman KB, et al. Atherosclerosis of the ascending aorta. Prevalence and role as an independent predictor of cerebrovascular events in cardiac patients. Stroke. 1994; 25: 2010-2016. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/8091446
Laperche T, Laurian C, Roudaut R, Steg PG. Mobile thromboses of the aortic arch without aortic debris. A transesophageal echocardiographic finding associated with unexplained arterial embolism. The filiale echocardiographie de la societe francaise de cardiologie. Circulation. 1997; 96: 288-294. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/9236447
Tribouilloy C, Peltier M, Colas L, Senni M, Ganry O, et al. Fibrinogen is an independent marker for thoracic aortic atherosclerosis. The Am J Cardiol. 1998; 81: 321-326. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/9468075
Tribouilloy CM, Peltier M, Iannetta Peltier MC, Trojette F, Andrejak M, et al. Plasma homocysteine and severity of thoracic aortic atherosclerosis. Chest. 2000; 118: 1685-1689. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/11115459
Young KC, Benesch CG. Transesophageal echocardiography screening in subjects with a first cerebrovascular ischemic event. J Stroke Cerebrovasc Dis. 2011; 20: 503-509. PubMed: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2997382/
Sen S, Oppenheimer SM, Lima J, Cohen B. Risk factors for progression of aortic atheroma in stroke and transient ischemic attack patients. Stroke. 2002; 33: 930-935. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/11935039
Montgomery DH, Ververis JJ, McGorisk G, Frohwein S, Martin RP, et al. Natural history of severe atheromatous disease of the thoracic aorta: A transesophageal echocardiographic study. J Am Coll Cardiol. 1996; 27: 95-101. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/8522717
Geraci A, Weinberger J. Natural history of aortic arch atherosclerotic plaque. Neurology. 2000; 54: 749-751. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/10680818
Davila-Roman VG, Westerhausen D, Hopkins WE, Sicard GA, Barzilai B. Transesophageal echocardiography in the detection of cardiovascular sources of peripheral vascular embolism. Ann Vasc Surg. 1995; 9: 252-260. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/7632553
Hart RG, Sharma M, Mundl H, Kasner SE, Bangdiwala SI, et al. Rivaroxaban for stroke prevention after embolic stroke of undetermined source. N Engl J Med. 2018; 378: 2191-2201. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/29766772
Diener Hea. Re-spect esus: Dabigatran versus acetylsalicylic acid for stroke prevention in patients with embolic stroke of undetermined source. Presented at the world stroke congress, montreal, canada, on 17 october 2018. 2018.