Diagnostic Yield of Cardiac CT to Detect Cardiac Thrombi in Patients With Acute Ischemic Stroke (AIS of HEARTS)

Q: What are the key findings of this study?

Cardiac computed tomography incorporated into the acute stroke imaging protocol successfully detected cardiac thrombi in 6.2% of patients with acute ischemic stroke.

Q: What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Acute ischemic stroke (n=3919). Intervention: Cardiac computed tomography (CT). Primary outcome: Proportion of patients with a cardiac thrombus detected on acute cardiac CT.

Q: What does this research mean for the field?

Integrating cardiac CT into the acute stroke imaging protocol is feasible, detects cardiac thrombi in approximately 6% of patients with a higher diagnostic yield than transthoracic echocardiography, and identifies patients at increased risk for 90-day mortality. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

Shan Sui Nio; Daniel S. Green; Alexander Berry-Noronha; Leon A. Rinkel; Chiel F.P. Beemsterboer; Md Golam Hasnain; R. Nils Planken; Adriënne van Randen; Sinan Al-Hadethi; Mirre G.M. Hilt; Deborah S.A. Ruhe; Berto J. Bouma; S Matthijs Boekholdt; Beng Lim Alvin Chew; Joshua Fridgant; Luis Mena-Romo; Dong Hyun Kim; Shuyu Guo; Yassar Alamri; Joel Winders; Sajith C. Senadeera; Anthony T. Lim; John Fink; Melissa Leung; Dennis Cordato; Mark W. Parsons; N. Spratt; Carlos Garcia-Esperon; Teddy Y. Wu; Jonathan M. Coutinho; on behalf of the AIS of HEARTS Collaborators

doi:10.1161/strokeaha.126.055575

Key result

Acute cardiac CT detects cardiac thrombus in ~6% of ischemic stroke patients.

n=3,919

Figures

Why the study?

Cardiac CT during acute stroke imaging is an emerging modality to detect cardiac thrombi, but its yield in patients with acute ischemic stroke needed to be determined.

Does cardiac CT acquired during the acute stroke imaging protocol improve the detection of cardiac thrombi compared to transthoracic echocardiography in patients with acute ischemic stroke?

Key Points

To determine the diagnostic yield of cardiac CT for detecting cardiac thrombi during acute stroke imaging and to evaluate associated 90-day clinical outcomes.
Analyzed individual patient data across four prospective cohorts (AIS of HEARTS, NCT07165093) comprising 3919 patients with acute ischemic stroke scanned between May 2018 and June 2024.
Patients underwent ECG-gated (n=1457) or non-ECG-gated (n=2462) cardiac CT alongside acute stroke imaging, with subsets undergoing transthoracic (n=1323) or transesophageal (n=126) echocardiography.
Multivariable logistic regression adjusted for demographic and clinical confounders to evaluate 90-day functional outcome (modified Rankin Scale score), mortality, and recurrent ischemic stroke.
Cardiac CT detected 254 thrombi in 243 of 3919 patients (6.2%), showing significantly higher diagnostic yield than transthoracic echocardiography (OR, 7.4 [95% CI, 4.0–15.1], P <0.001).
Median additional scan time was 6 minutes (IQR, 5–7) for ECG-gated and 13 seconds (IQR, 12–61) for non-ECG-gated CT, with a median additional radiation dose of 2.9 mSv (IQR, 1.6–4.1).
Patients with thrombi experienced higher 90-day mortality (33% versus 15%, adjusted OR, 1.6 [95% CI, 1.1–2.3]) and worse modified Rankin Scale scores (median 3 versus 2, adjusted OR, 1.6 [95% CI, 1.2–2.0]), but similar recurrent stroke rates (5% versus 4%, adjusted OR, 1.4 [95% CI, 0.7–2.5]).

Study Design

Type

Meta-Analysis (n=3,919)

Multicenter

Yes

Structured PICO

Does cardiac CT acquired during the acute stroke imaging protocol improve the detection of cardiac thrombi compared to transthoracic echocardiography in patients with acute ischemic stroke?

P

Population

3,919 adult patients with acute ischemic stroke who underwent cardiac CT as part of the acute stroke scan protocol, evaluated for the presence of cardiac thrombi.

E

Exposure

Cardiac CT (either ECG-gated or non-ECG-gated) acquired as an extension of the acute stroke scan protocol (median additional scan time of 6 minutes for ECG-gated and 13 seconds for non-ECG-gated).

C

Comparator

Transthoracic echocardiography (TTE) in the subset of patients (n=1,323) who underwent both imaging modalities.

O

Outcome

Proportion of patients with a cardiac thrombus detected on acute cardiac CT (located in the left atrial appendage, left atrium, or left ventricle).surrogate

Integrating cardiac CT into the acute stroke imaging protocol is feasible and demonstrates a 7-fold higher diagnostic yield for detecting cardioembolic thrombi compared to standard transthoracic echocardiography.

Limitations

Heterogeneity between participating hospitals in scan protocols and cardiac thrombi definitions.
The left ventricle was not visualized on cardiac CT in 31% of patients, potentially missing some thrombi.
Patients with transient ischemic attack (TIA) were excluded, limiting generalizability to milder cases.
Echocardiography was only performed in approximately one-third of the patients.
Follow-up methodology relied largely on reviewing medical records, which may have underestimated clinical events.
Lack of a central core lab committee to systematically assess all cardiac CT scans.
Residual confounding in the clinical outcome analyses cannot be fully excluded due to the observational design.
Heterogeneity between participating hospitals in scan protocol and cardiac thrombi definition
Left ventricle was not visualized on cardiac CT in 31% of cases, likely missing some thrombi
Excluded patients with TIA, meaning results may not apply to milder symptoms
Echocardiography was only performed in approximately one-third of patients
Follow-up relied largely on medical files, potentially underestimating events
No core lab committee to centrally assess all cardiac CT scans
Observational design leaves potential for residual confounding in outcome analyses

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

May support adding cardiac CT to acute stroke protocols for better thrombus yield; leaves open whether routine use improves outcomes pending trials.

Abstract

BACKGROUND: Cardiac computed tomography (CT) acquired during the acute stroke imaging protocol is an emerging modality to detect cardiac thrombi. We determined its yield in patients with acute ischemic stroke. METHODS: We performed a 1-stage individual patient data meta-analysis of 4 prospective observational cohorts (AIS of HEARTS [Acute Ischemic Stroke of Heart-Related Embolic Sources Detected on Acute Cardiac CT Scans]), including patients with acute ischemic stroke who underwent ECG-gated or non-ECG-gated cardiac CT between May 2018 and June 2024. We excluded patients with transient ischemic attack or stroke mimics. The primary outcome was the proportion of patients with a thrombus on cardiac CT. Secondary outcomes were additional scan time, radiation dose, comparison with echocardiography, and 90-day outcomes. We performed logistic regression analyses to compare 90-day outcomes between patients with and without thrombus, adjusting for age, sex, history of atrial fibrillation, ischemic heart disease, chronic heart failure, stroke or transient ischemic attack, anticoagulant use, prestroke modified Rankin Scale score, National Institutes of Health Stroke Scale score, large vessel occlusions, and intravenous thrombolysis, as appropriate for each outcome. Median additional scan time was 6 minutes (IQR, 5-7) for ECG-gated and 13 seconds (IQR, 12-61) for non-ECG-gated cardiac CT. Median additional radiation dose was 2.9 mSv (IQR, 1.6-4.1). Patients with thrombi had higher 90-day mortality (33% versus 15%, adjusted odds ratio, 1.6 [95% CI, 1.1-2.3]) and worse modified Rankin Scale scores (median modified Rankin Scale score 3 versus 2, adjusted odds ratio, 1.6 [95% CI, 1.2-2.0]), but similar recurrent stroke rates (5% versus 4%, adjusted odds ratio, 1.4 [95% CI, 0.7-2.5]). CONCLUSIONS: Implementing cardiac CT into the acute stroke imaging protocol is feasible, detects thrombi in ≈6% of patients, and has a higher yield than transthoracic echocardiography. Cardiac thrombi were associated with higher mortality, but not higher stroke recurrence. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT07165093.

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Cite This Study

Nio et al. (2026) conducted a meta-analysis in Acute ischemic stroke (n=3,919). Cardiac computed tomography (CT) was evaluated on Proportion of patients with a cardiac thrombus detected on acute cardiac CT. Cardiac computed tomography incorporated into the acute stroke imaging protocol successfully detected cardiac thrombi in 6.2% of patients with acute ischemic stroke.

synapsesocial.com/papers/6a2115f6d499ed480b16f08e https://doi.org/10.1161/strokeaha.126.055575

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Diagnostic Yield of Cardiac CT to Detect Cardiac Thrombi in Patients With Acute Ischemic Stroke (AIS of HEARTS)

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Diagnostic Yield of Cardiac CT to Detect Cardiac Thrombi in Patients With Acute Ischemic Stroke (AIS of HEARTS)

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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