1. The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey

2. Echocardiography at St George’s Hospital Each echocardiogram is estimated to cost £55 12,000 requests are received per year Total cost of £660,000 30-35 echocardiograms performed per day Average outpatient wait for routine echo is 6 weeks Only “urgent” inpatient echos are done during admission

3. Echocardiography in stroke management at St George’s Hospital Already a filtering system in place Only those with a cardiac history (AF, previous MI, murmur) are accepted Those requests without this are filtered out, unless you persist!

4. To estimate the frequency of management altering abnormal echocardiograms in stroke patients at St George’s Hospital Aim of this audit

5. Methods All admissions to Thomas Young Ward Between 1-1-01 and 1-6-01 Details from ward register Search for echocardiogram results on all Review appropriate notes

6. Patient details from ward register Abnormal echocardiogram report? No Management altering abnormality? Yes No Yes Did it alter management? Echocardiogram result from cardiology database

7. Thomas Young ward register Name Hospital number DOB Date of admission/discharge Consultant Diagnosis Follow up arrangements

8. Echocardiogram search On the hospital number Name and/or DOB

9. Results

10. Admissions Number Total 103 Male56 Female47 Mean no. admissions per month20 Mean age72yrs Age range35-98yrs

11. Echocardiogram EchocardiogramNo echocardiogram Total24(23.3%)79(76.7%) Male15(26.8%)41(73.2%) Female9(19.1%)38(80.9%) Mean age66yrs74yrs Age range35-90yrs48-98yrs

14. Echocardiograms Echocardiogram Total24 Entirely normal10 Abnormal14

16. Value of echocardiogram 1 in 24 significantly positive result Almost 4% yield Have I just shot myself in the foot?

17. Mr DT History 49 year old Aphasia Right hemiparesis Febrile Former IV drug user

18. Mr DT Examination Clubbed, splinter haemorrhages Temp 39 HR 100/min BP 110/58 Pan systolic murmur No splenomegaly Diagnosis “Bacterial endocarditis and embolic CVA” Treatment IV cefotaxime, flucloxacillin and gentamicin

19. Summary 103 stroke patients admitted to Thomas Young ward 24 had echocardiograms performed Far more requested though! 10 were entirely normal Only 1 had a results that would alter management Clinical features in that case completely supported the request for an echocardiogram

20. Low Yield of Transthoracic Echocardiography for Cardiac Source of Embolism Vedat Sansoy et al American Journal of Cardiology 1995;75:166-69 University of Virginia Medical Centre

21. Low Yield of Transthoracic Echocardiography for Cardiac Source of Embloism 1,010 consecutive patients admitted with CVAs or TIAs 325 controls Exclusion criteria: MI within the prior 6weeks, or known bacterial endocarditis

22. Criteria used for determining cardiac source of embolism Highly probable causes:Definite left ventricular Definite left atrial thrombus Definite left atrial myxoma Definite valvular vegetation Possible causes:Possible left ventricular Possible left atrial thrombus Possible valvular vegetation Atrial septal defect Doubtful causes:Mitral valve prolapse Mitral annular calcification

23. Results Cases (n=1010)Controls (n=325) Male521 [52%]166 [51%] Female 489 [48%]159 [49%] Mean age 67yrs65yrs

24. Cases (n=1010) Number (percentage) CVA677 (67%) TIA313 (31%) Unclear20 (2%)

25. Results CasesControls Definite left ventricular thrombus2.8%5.2% Definite left atrial thrombus0.0%0.0% Definite valvular vegetation0.0%2.5% Left atrial myxoma0.0%0.0% Possible left ventricular thrombus2.0%3.0% Possible left atrial thrombus0.3%0.0% Possible valvular vegetation2.0%2.0% Atrial septal defect0.3%0.6% Mitral valve prolapse5.0%5.0% Mitral annular calcification31.0%26.0%

26. Results CasesControls Atrial fibrillation14%15% Systemic hypertension48%29% Diabetes mellitus25%25% IHD15%33% CCF6%36%

27. Percentage of patients with definite, probable and doubtful cardiac source of embolus as determined by Transthoracic two-dimensional Echocardiography after adjustment for age and various cardiovascular conditions CasesControls Definite cardiac source5%5% Probable cardiac source 4%4% Doubtful cardiac source 37%30%

28. Patients anticoagulated following a positive echocardiograph result Cases Definite cardiac source50% Probable cardiac source 30% Doubtful cardiac source 0% The remainder were not treated with anticoagulants because of contraindications that were known before echocardiography

29. Management was altered in only 22 of 1010 patients (2%) of whom 17 had pre-existing and known clinical and/or electrocardiographic abnormalities

30. Other findings in cases of definite or possible thrombus Definite Possible Q waves on ECG 54%41% LBBB18%11% CCF43%26% AF25%30% Only 23% had none of these abnormalities

31. Conclusion Limited resources in echocardiogram department Over 25% of patients with a CVA receive an echocardiogram at St George’s Hospital It is very unlikely to alter management Long outpatient waits for echocardiograms Only urgent echos performed as inpatient Echocardiography in CVA management is an area were there is a need to rationalize our requests

32. Take home message Low yield for transthoracic echocardiography in stroke management Most cases have other cardiological features/abnormalities Echocardiography is a valuable and over used resource We need to be far more selective in our use of echocardiography in stroke management Long waiting lists for routine echocardiography could be improved as a result