title: Transesophageal echocardiography screening in subjects with a first cerebrovascular ischemic event.
abstract: Our goal was to develop decision guides to predict the presence of a high-risk source of embolus and to predict a change in management following transesophageal echocardiography (TEE) in subjects who present with a first cerebral ischemic event. We conducted a retrospective review of subjects age ≥18 years who underwent TEE after a first ischemic event and were admitted to our stroke service between 2004 and 2007 (n = 287). A high-risk source of embolus and a change in clinical management (including medication changes or subsequent testing) were analyzed as separate endpoints, using multivariate techniques and receiver operating characteristic curves. We found that 14.3% of the subjects had a high-risk source, and an additional 61.3% had a potential (or low-risk) source of embolus. Increasing age and no history of diabetes mellitus were independently associated with a high-risk source of embolus. TEE would be recommended for nondiabetic individuals age ≥66 years (sensitivity, 68%; specificity, 76%). The area under the curve (AUC) for detecting a high-risk source was 0.773. TEE results changed medications or clinical management in 30.3% of the subjects. Current smokers were less likely to undergo a change in management. The AUC was uninformative (0.56) for predicting changes in management. Subjects presenting with a first ischemic event age ≥66 years may benefit from TEE. Although changes in management occurred in at least 30% of our cohort, no factors that predicted a change in management better than chance alone could be identified.
authors.affiliation: Department of Neurology, University of Rochester Medical Center, 575 Elmwood Ave., Rochester, NY 14620, USA. kate_young@urmc.rochester.edu
authors.forename: Kate C
authors.initials: KC
authors.lastname: Young
authors.forename: Curtis G
authors.initials: CG
authors.lastname: Benesch
mesh_terms: D000368:Aged; D001018:Aortic Diseases / Q000150:complications / Q000000981:diagnostic imaging* / Q000628:therapy; D002545:Brain Ischemia / Q000000981:diagnostic imaging* / Q000209:etiology / Q000628:therapy; D016009:Chi-Square Distribution; D003661:Decision Support Techniques; D017548:Echocardiography, Transesophageal; D005260:Female; D006331:Heart Diseases / Q000150:complications / Q000000981:diagnostic imaging* / Q000628:therapy; D006801:Humans; D020766:Intracranial Embolism / Q000000981:diagnostic imaging* / Q000209:etiology / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009518:New York; D016017:Odds Ratio; D011237:Predictive Value of Tests; D012372:ROC Curve; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013927:Thrombosis / Q000150:complications / Q000000981:diagnostic imaging* / Q000628:therapy
references.citation: Echocardiography. 2006 Mar;23(3):202-7
references.pmid: 16524390
references.citation: J Neurol Neurosurg Psychiatry. 2002 Jul;73(1):29-33
references.pmid: 12082041
references.citation: J Neurol Neurosurg Psychiatry. 2002 Jul;73(1):21-8
references.pmid: 12082040
references.citation: Echocardiography. 1992 Mar;9(2):161-8
references.pmid: 10149880
references.citation: Stroke. 1994 Jan;25(1):23-8
references.pmid: 8266377
references.citation: Clin Chem. 1993 Apr;39(4):561-77
references.pmid: 8472349
references.citation: Stroke. 1996 Nov;27(11):1951-7
references.pmid: 8898797
references.citation: J Neurol Neurosurg Psychiatry. 2003 Feb;74(2):283-4; author reply 284
references.pmid: 12531977
references.citation: Stroke. 2006 Mar;37(3):859-64
references.pmid: 16439702
references.citation: J Neurol Neurosurg Psychiatry. 2005 Dec;76(12):1654-8
references.pmid: 16291889
references.citation: AJNR Am J Neuroradiol. 2007 Jan;28(1):104-10
references.pmid: 17213434