the value of echocardiography in stroke management asjid qureshi, specialist registrar to dr s...
TRANSCRIPT
![Page 1: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/1.jpg)
The value of echocardiography in stroke management
Asjid Qureshi,
Specialist registrar to Dr S Nussey
![Page 2: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/2.jpg)
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
![Page 3: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/3.jpg)
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!
![Page 4: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/4.jpg)
To estimate the frequency of management altering abnormal echocardiograms in stroke patients at St
George’s Hospital
Aim of this audit
![Page 5: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/5.jpg)
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
![Page 6: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/6.jpg)
Patient details from ward register
Abnormal echocardiogram report?
No
Management altering abnormality?
Yes
NoYes
Did it alter management?
Echocardiogram result from cardiology database
![Page 7: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/7.jpg)
Thomas Young ward register
• Name• Hospital number• DOB• Date of admission/discharge• Consultant• Diagnosis• Follow up arrangements
![Page 8: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/8.jpg)
Echocardiogram search
• On the hospital number
• Name and/or DOB
![Page 9: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/9.jpg)
Results
![Page 10: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/10.jpg)
Admissions
Number
Total 103
Male 56
Female 47
Mean no. admissions per month 20
Mean age 72yrs
Age range 35-98yrs
![Page 11: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/11.jpg)
Echocardiogram
Echocardiogram No echocardiogram
Total 24(23.3%) 79(76.7%)
Male 15(26.8%) 41(73.2%)
Female 9(19.1%) 38(80.9%)
Mean age 66yrs 74yrs
Age range 35-90yrs 48-98yrs
![Page 12: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/12.jpg)
Admissions per consultant
14
10
8
10
7
9
6
12
6
1
15
02468
10121416P
anah
loo
Bak
er
Bou
rke/
Kie
ly
Ray
ner/
Tho
mas
Cot
tee
New
ton
Eas
twoo
d
McG
rego
r
Max
wel
l/T
ibbs
Ora
m
Nus
sey
Num
ber
of p
atie
nts
![Page 13: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/13.jpg)
Echocardiograms per consultant
4 0 2 1 0 2 2 3 3 1 3
10
10
6
9
7
7
4
9
3
0
12
02468
10121416P
anah
loo
Bak
er
Bou
rke/
Kie
ly
Ray
ner
/Th
omas
Cot
tee
New
ton
Eas
twoo
d
McG
rego
r
Max
wel
l/Tib
bs
Ora
m
Nu
ssey
Nu
mb
er o
f p
atie
nts
No echoEcho
![Page 14: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/14.jpg)
Echocardiograms
Echocardiogram
Total 24
Entirely normal 10
Abnormal 14
![Page 15: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/15.jpg)
Echocardiogram results
10
4
2
1
3
1
11
1 Normal
Mild LV/LA dilatation
Sclerotic AV
Patent foramen Ovale
LVH
Aortic stenosis
Mildly dilated prox.Aorta
Vegetation
Moderate MR
![Page 16: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/16.jpg)
Value of echocardiogram
• 1 in 24 significantly positive result
• Almost 4% yield
Have I just shot myself in the foot?
![Page 17: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/17.jpg)
Mr DT
History49 year old AphasiaRight hemiparesisFebrileFormer IV drug user
![Page 18: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/18.jpg)
Mr DT
Examination
Clubbed, splinter haemorrhagesTemp 39HR 100/minBP 110/58Pan systolic murmur No splenomegaly
Diagnosis“Bacterial endocarditis and embolic CVA”
TreatmentIV cefotaxime, flucloxacillin and gentamicin
![Page 19: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/19.jpg)
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
![Page 20: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/20.jpg)
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
![Page 21: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/21.jpg)
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, orknown bacterial endocarditis
![Page 22: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/22.jpg)
Criteria used for determining cardiac source of embolism
Highly probable causes: Definite left ventricularDefinite left atrial thrombusDefinite left atrial myxomaDefinite valvular vegetation
Possible causes: Possible left ventricularPossible left atrial thrombusPossible valvular vegetationAtrial septal defect
Doubtful causes: Mitral valve prolapse
Mitral annular calcification
![Page 23: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/23.jpg)
Results
Cases (n=1010) Controls (n=325)
Male 521 [52%] 166 [51%]
Female 489 [48%] 159 [49%]
Mean age 67yrs 65yrs
![Page 24: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/24.jpg)
Cases (n=1010)
Number (percentage)
CVA 677 (67%)
TIA 313 (31%)
Unclear 20 (2%)
![Page 25: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/25.jpg)
Results
CasesControls
Definite left ventricular thrombus 2.8% 5.2%
Definite left atrial thrombus 0.0% 0.0%
Definite valvular vegetation 0.0% 2.5%
Left atrial myxoma 0.0% 0.0%
Possible left ventricular thrombus 2.0% 3.0%
Possible left atrial thrombus 0.3% 0.0%
Possible valvular vegetation 2.0% 2.0%
Atrial septal defect 0.3% 0.6%
Mitral valve prolapse 5.0% 5.0%
Mitral annular calcification 31.0% 26.0%
![Page 26: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/26.jpg)
Results
Cases Controls
Atrial fibrillation 14% 15%
Systemic hypertension 48% 29%
Diabetes mellitus 25% 25%
IHD 15% 33%
CCF 6% 36%
![Page 27: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/27.jpg)
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 source 5% 5%
Probable cardiac source 4% 4%
Doubtful cardiac source 37% 30%
![Page 28: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/28.jpg)
Patients anticoagulated following a positive echocardiograph result
Cases
Definite cardiac source 50%
Probable cardiac source 30%
Doubtful cardiac source 0%
The remainder were not treated with anticoagulants because of
contraindications that were known before echocardiography
![Page 29: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/29.jpg)
Management was altered in only 22 of 1010 patients
(2%) of whom 17 had pre-existing and known clinical
and/or electrocardiographic abnormalities
![Page 30: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/30.jpg)
Other findings in cases of definite or possible thrombus
Definite Possible
Q waves on ECG 54% 41%
LBBB 18% 11%
CCF 43% 26%
AF 25% 30%
Only 23% had none of these abnormalities
![Page 31: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/31.jpg)
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
![Page 32: The value of echocardiography in stroke management Asjid Qureshi, Specialist registrar to Dr S Nussey](https://reader036.vdocuments.pub/reader036/viewer/2022062715/56649d8e5503460f94a76b34/html5/thumbnails/32.jpg)
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