Transthoracic Transthoracic Echocardiography in Echocardiography in

Cerebrovascular DiseaseCerebrovascular Disease

Nisha I Parikh, MD MPHNisha I Parikh, MD MPH

Noninvasive Imaging ConferenceNoninvasive Imaging Conference

May 14May 14thth 2008 2008

OverviewOverview

Pathophysiology of CVAPathophysiology of CVA Role of TTE in CVARole of TTE in CVA Role of PFO testing in CVARole of PFO testing in CVA Cost Effectiveness of TTE in StrokeCost Effectiveness of TTE in Stroke Epidemiologic TTE Markers of Epidemiologic TTE Markers of

Incident CVAIncident CVA

Pathophysiology of CVAPathophysiology of CVA

Ischemic StrokeIschemic Stroke

Thrombotic Embolic

Large Vessel Small Vessel

Extracranial Intracranial

Definite Cardioembolic Source

Possible Cardioembolic Source

Ascending Aortic Atheroma

True Unknown Embolic Source

* Common Carotid* ICA, ECA* Vertebral artery

* Circle of Willis* Proximal Branches

Cerebrovascular Circulation

Up to date

Cardioembolic Sources- Cardioembolic Sources- DefiniteDefinite

Left atrial thrombusAtrial fibrillationSustained atrial flutter

Recent AMI

Rheumatic mitral or aortic diseaseMechanical or bioprosthetic valve

Low EF < 30%Chronic AMI EF < 28%

Dilated Cardiomyopathy

Endocarditis

Atrial myxoma

Cardioembolic Sources-Cardioembolic Sources-PossiblePossible

PFOAtrial septal aneurysm PFO with atrial septal an.

Mitral Annular Calcium

Mitral Valve Strands

LV aneurysm

Isolated left atrial smoke

LV thrombusLV thrombus

Large Atrial MyxomaLarge Atrial Myxoma

Role of TTE in CVARole of TTE in CVADiagnosis and ManagementDiagnosis and Management

Echocardiography in CVAEchocardiography in CVA

Appropriateness Criteria for Echocardiography

“ Symptoms potentially due to suspected cardiac etiology, including but not limited to dyspnea, shortness of breath, lightheadedness, syncope, TIA, cerebrovascular events” Score: 9 (Max=9)

Douglas et al. JACC

Review: TTE abnormalities in Review: TTE abnormalities in patients < 45 years of agepatients < 45 years of age

Beattie, Cohen, Manning, Douglas, Journal of Internal Medicine, 1998

Review: TTE abnormalities in Review: TTE abnormalities in patients patients ≥≥ 45 years of age 45 years of age

Beattie, Cohen, Manning, Douglas, Journal of Internal Medicine, 1998

““Therapy Implications of Transthoracic Therapy Implications of Transthoracic Echocardiography in Acute Ischemic Stroke Echocardiography in Acute Ischemic Stroke

PatientsPatients”” Prospective observational studyProspective observational study Évora, PortugalÉvora, Portugal TTE on all patients admitted to hospital TTE on all patients admitted to hospital

with ischemic stroke, in sinus rhythm with ischemic stroke, in sinus rhythm (mean age 76)(mean age 76)

January 7, 2002, to October 16, 2003. January 7, 2002, to October 16, 2003. Findings compatible with heart diseases Findings compatible with heart diseases

that would indicate anticoagulation as that would indicate anticoagulation as beneficial were identified. beneficial were identified.

de Abreu et al, J. Stroke 2005

FindingsFindings #(%)#(%)

No findings suggesting need of No findings suggesting need of anticoagulationanticoagulation

273 (62.8) 273 (62.8)

Dilated cardiopathyDilated cardiopathy 83 (19.1)83 (19.1)

Anterior wall dyskinesisAnterior wall dyskinesis 27 (6.2)27 (6.2)

Left ventricle ejection fraction Left ventricle ejection fraction <35%<35% 16 (3.7)16 (3.7)

Mitral valve stenosis with left Mitral valve stenosis with left atria >55 mmatria >55 mm

9 (2.1) 9 (2.1)

Intracardiac massesIntracardiac masses 2 (0.5) 2 (0.5)

Valve prosthesisValve prosthesis 1 (0.2)1 (0.2)

Mitral valve stenosis with left Mitral valve stenosis with left atria >55 mm+dilated atria >55 mm+dilated cardiopathycardiopathy

7 (1.6) 7 (1.6)

Dilated cardiopathy+anterior wall Dilated cardiopathy+anterior wall dyskinesisdyskinesis

9 (2.1) 9 (2.1)

Dilated cardiopathy+left ventricle Dilated cardiopathy+left ventricle ejection fraction <35%ejection fraction <35% 8 (1.8)8 (1.8)

Total 435 (100.1) Total 435 (100.1)

Echocardiography Findings (n=435)

de Abreu et al, J. Stroke 2005

Author ConclusionsAuthor Conclusions

““In our study, transthoracic In our study, transthoracic echocardiography had therapy echocardiography had therapy implications in 37.2% of ischemic implications in 37.2% of ischemic stroke patients in sinus rhythm.” stroke patients in sinus rhythm.”

““Transthoracic echocardiography Transthoracic echocardiography should be considered an essential should be considered an essential test in all ischemic stroke patients in test in all ischemic stroke patients in sinus rhythm.” sinus rhythm.”

de Abreu et al, J. Stroke 2005

Usefulness of Cardiovascular Investigations Usefulness of Cardiovascular Investigations

in Stroke Managementin Stroke Management The outcome of cardiovascular The outcome of cardiovascular

investigations in 200 patients with investigations in 200 patients with stroke/transient ischemic attack stroke/transient ischemic attack

Stroke Prevention Clinic Stroke Prevention Clinic Ontario, CanadaOntario, Canada

TTE in 71% (142/200) of patientsTTE in 71% (142/200) of patients Pertinent cardiac findings were uncovered Pertinent cardiac findings were uncovered

in only 6 (4%) patients in only 6 (4%) patients TTE did not alter antithrombotic therapy in TTE did not alter antithrombotic therapy in

any of the 142 patients studiedany of the 142 patients studied

Douen et al., Stroke 2007

Patent Foramen OvalePatent Foramen Ovale

10-20% of Adults

Usually Asymptomatic

Echo: PFOEcho: PFO

Therapeutic options for PFO Therapeutic options for PFO associated with CVAassociated with CVA

Anticoagulation Anticoagulation

Antiplatelet therapyAntiplatelet therapy

Surgical PFO closureSurgical PFO closure

Transcatheter closureTranscatheter closure

PFO Closure DevicePFO Closure Device

““Effect of Medical Treatment in Stroke Patients With Effect of Medical Treatment in Stroke Patients With Patent Foramen Ovale Patent Foramen Ovale

Patent Foramen Ovale in Cryptogenic Stroke Study“Patent Foramen Ovale in Cryptogenic Stroke Study“

The PFO in Cryptogenic Stroke Study The PFO in Cryptogenic Stroke Study 42-center study 42-center study TEE findings in patients randomly assigned to TEE findings in patients randomly assigned to

warfarin or aspirin in the Warfarin-Aspirin warfarin or aspirin in the Warfarin-Aspirin Recurrent Stroke StudyRecurrent Stroke Study

630 stroke patients were enrolled630 stroke patients were enrolled- 312 (49.5%) were randomized to warfarin - 312 (49.5%) were randomized to warfarin - 318 (50.5%) to aspirin - 318 (50.5%) to aspirin

265 with cryptogenic stroke and 365 with known 265 with cryptogenic stroke and 365 with known stroke subtypesstroke subtypes

End points, recurrent ischemic stroke or death End points, recurrent ischemic stroke or death PFO present in 203 patients (33.8%)PFO present in 203 patients (33.8%)

Homma et al, Circ 2002

Copyright ©2002 American Heart Association

Homma, S. et al. Circulation 2002;105:2625-2631

Kaplan-Meier curves of cumulative risk of recurrent stroke or death stratified by baseline

PFO status

Authors ConclusionAuthors Conclusion

We demonstrate that when the We demonstrate that when the stroke patients are treated medically, stroke patients are treated medically, the rate of recurrent stroke or death the rate of recurrent stroke or death is similar between patients with and is similar between patients with and without PFO. without PFO.

Homma et al, Circ 2002

Cost Effectiveness of Cost Effectiveness of TTE in CVATTE in CVA

McNamara, R. L. et. al. Ann Intern Med 1997;127:775-787

Nine possible diagnostic strategies for patients with stroke

Cost-effectiveness of diagnostic strategies compared with the treat-none strategy

McNamara, R. L. et. al. Ann Intern Med 1997;127:775-787

Cost Effectiveness of TTE in Cost Effectiveness of TTE in CVACVA

Transthoracic echocardiography, alone or in sequence with Transthoracic echocardiography, alone or in sequence with transesophageal echocardiography, was not cost-effective transesophageal echocardiography, was not cost-effective compared with transesophageal echocardiography* compared with transesophageal echocardiography*

All strategies containing TTE were dominated by others and All strategies containing TTE were dominated by others and were eliminated from the analysis**were eliminated from the analysis**

Current evidence on cost-effectiveness is insufficient to Current evidence on cost-effectiveness is insufficient to justify widespread use of echocardiography in stroke justify widespread use of echocardiography in stroke patients. patients.

Additional research on recurrent stroke risk may contribute Additional research on recurrent stroke risk may contribute to a better understanding of the circumstances under which to a better understanding of the circumstances under which echocardiography will be cost-effectiveechocardiography will be cost-effective - in patients with intracardiac thrombus- in patients with intracardiac thrombus - on the efficacy of AC in reducing that risk- on the efficacy of AC in reducing that risk

* McNamara, R. L. et. al. Ann Intern Med 1997;127:775-787** Meenan RT et al, Med Dec Making, 2007

Echocardiographic Predictors Echocardiographic Predictors of CVA from Epidemiologic of CVA from Epidemiologic

StudiesStudies

Valvular CalcificationValvular Calcification

Valvular Calcification: Valvular Calcification: Framingham Heart StudyFramingham Heart Study

MAC and stroke of RR=2.10 (95% CI 1.24 to MAC and stroke of RR=2.10 (95% CI 1.24 to 3.57; P = 0.006). 3.57; P = 0.006).

Continuous relation between the incidence of Continuous relation between the incidence of stroke and the severity of MAC; each stroke and the severity of MAC; each millimeter of thickening as shown on the millimeter of thickening as shown on the echocardiogram represented RR of stroke of echocardiogram represented RR of stroke of 1.24 (95% CI, 1.12 to 1.37; P less than 1.24 (95% CI, 1.12 to 1.37; P less than 0.001). 0.001).

Even when subjects with coronary heart Even when subjects with coronary heart disease or CHF were excluded from the disease or CHF were excluded from the analysis, subjects with MAC still had twice the analysis, subjects with MAC still had twice the risk of stroke. risk of stroke.

Benjamin EJ et al, NEJM 1992

Copyright ©2005 American Heart Association

Kizer, J. R. et al. Stroke 2005;36:2533-2537

Strong Heart StudyB. MAC and incident stroke. B. AV sclerosis and

incident stroke

LA SizeLA Size

Copyright ©1995 American Heart Association

Benjamin, E. J. et al. Circulation 1995;92:835-841

Age-adjusted cumulative incidence of stroke by tertile of left atrial (LA) size in men and women

MEN WOMEN

LV Mass: ARICLV Mass: ARICTable 4. HRs for Ischemic Stroke: Results of Multivariable Proportional-Hazards Regression Analysis by LVMI (10 g/m2.7 increments)

LVMI

P Value

Unadjusted 1.36 (1.25,1.49) <0.0001

Adjusted for age 1.33 (1.22,1.46) <0.0001

Adjusted for age and sex 1.33 (1.22,1.45) <0.0001

Multivariable adjusted (1) 1.15 (1.02,1.29) 0.02

Multivariable adjusted (2) 1.17 (1.03,1.32) 0.02

Multivariable adjusted (3) 1.16 (1.02,1.32) 0.02

Data expressed as HR (95% CI).

Adjusted for age, sex, hypertension, SBP, smoking, DM, total to HDL cholesterol ratio, BMI, prevalent coronary heart disease/congestive heart failure, and left ventricular ejection fraction.

Multivariable model 1+LA size.

Multivariable model 1+LA size+mitral annular calcification. Addition of a variable for plaque/shadowing at any site on carotid ultrasound made no further change to the parameter estimates or P values.

Fox ER, Stroke, 2007

ConclusionsConclusions Cardioembolic Source of CVA may be present in 6-40% of Cardioembolic Source of CVA may be present in 6-40% of

patients depending on the population studiedpatients depending on the population studied

TTE is recommended as initial evaluation in CVATTE is recommended as initial evaluation in CVA

Assessment of PFO is controversial given a high population Assessment of PFO is controversial given a high population prevalence of this condition, uncertain treatment efficacy prevalence of this condition, uncertain treatment efficacy and lack of definite link to the disease state and lack of definite link to the disease state

The Cost Benefit of TTE in CVA has not been established The Cost Benefit of TTE in CVA has not been established and widespread use may preclude estimatesand widespread use may preclude estimates

MAC, LA size and LVM predict incident stroke MAC, LA size and LVM predict incident stroke