Key result
Routine TTE and Holter in stroke outpatients yield relevant findings in only ~4% despite high costs.
Why the study?
Prospective randomized studies assessing the clinical relevance of routine cardiovascular investigations in stroke patients are lacking, prompting an evaluation of their utilization, relevance, and economics in an ambulatory stroke clinic.
Observational (n=200)
No
Routine TTE/Holter drive most cardiovascular costs in stroke/TIA outpatients with low yield; leaves open value of selective testing.
BACKGROUND AND PURPOSE: There are no prospective randomized studies assessing the clinical relevance of routine cardiovascular investigations in stroke patients. The objective of this study was to evaluate the utilization, relevance, and economics of cardiovascular investigations in an ambulatory stroke clinic. METHODS: The outcome of cardiovascular investigations in 200 patients with stroke/transient ischemic attack diagnosed in a stroke prevention clinic was assessed. Transthoracic echocardiography (TTE) was assessed for detection of thrombus or mass, poor left ventricle function, and other structural abnormalities. ECG and Holter monitor were felt to be relevant if they showed atrial fibrillation/flutter. Investigations were deemed to be clinically pertinent if they brought about a shift treatment paradigm. RESULTS: TTE and Holter were performed in >70% of cases and accounted for approximately 94% of total cardiovascular cost. Relevant TTE findings were identified in 6 (4%) patients, which did not alter antithrombotic therapy. Only 2 new cases of atrial fibrillation were identified by both ECG and Holter. CONCLUSIONS: TTE and Holter appear to be costly low-yield procedures in this clinical setting. Prospective analyses may help to provide cost effective criteria for selection of appropriate cardiovascular studies in stroke management.
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Douen et al. (2007) conducted an observational in Stroke or transient ischemic attack (n=200). Routine cardiovascular investigations (TTE, ECG, and Holter monitoring) was evaluated on Clinically pertinent findings altering treatment paradigm (thrombus/mass, poor LV function, structural abnormalities on TTE; atrial fibrillation/flutter on ECG/Holter). Transthoracic echocardiography and Holter monitoring in stroke/TIA outpatients accounted for 94% of cardiovascular costs, with relevant TTE findings in 4% and 2 new atrial fibrillation cases.
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