The use of echocardiography for stroke and peripheral embolus: is it time for British/European guidelines?

The American College of Cardiology and the American Heart Association recommend echocardiography in patients with stroke or peripheral embolus who are less than 45 years of age or in those without evidence of cerebrovascular disease or other obvious cause.¹ There are no equivalent guidelines from British or European Cardiac Societies. The prevalence of stroke and peripheral embolus has made it a common indication for the use of echocardiography. Despite this, to our knowledge there has been no previously published evaluation of the use of echocardiography in such patients in the UK. We undertook a retrospective review of transthoracic (TTE) and transoesophageal echocardiogram (TOE) reports (n=7,870) over 37 months at St. Bartholomew’s Hospital department of cardiology. This identified 153 (1.9%) patients investigated for stroke/transient ischaemic attack (TIA) or peripheral embolus. Of these, six patients had two or more examinations producing a total of 160 reports; five reports were unrecorded and, therefore, 155 reports were analysed. A total of 12 reports (7.7%) identified possible cardiac sources of emboli with a further n=3 reporting spontaneous contrast in the left atrium. The potential embolic sources included patent foramen ovale (PFO)(n=3), aortic atheroma (n=3), aneurysmal atrial septum (n=2), mobile lesions on the mitral valve (n=3) and thrombus in the left atrial appendage (LAA)(n=1).
These results have led to the development of standardised criteria with the design of a template on the performing and reporting of echocardiograms in this type of patient.