Value of Cardiac Monitoring and Echocardiography in TIA and Stroke Patients

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SUMMARYOne hundred and eighty-four consecutive patients admitted to an Investigative Stroke Unit with transient ischemic attacks (TIA) and cerebral infarction (stroke) had 48-hour automated arrhythmia monitoring, 55 patients had additional Holter monitoring and 127 patients had 2-D echocardiography. One hundred and sixteen presented with stroke (63%) and 68 patients with TIA (37%). One hundred and twenty-two were men (66.3%) and 62 were women (33.7%), mean age 63.5 years, range 25-86.The monitoring identified twelve (6.5%) patients with significant arrhythmias undetected by history, examination and admission electrocardiogram: six with atrial fibrillation (AF), four with 2° heart block type Mobitz II and one each with 3° heart block and sick sinus syndrome. Two-D echocardiography showed a previously unknown potential source for cardiac emboli in 22 patients (17.3%): segmental ventricular disease in eleven, mitral valve prolapse in seven, left ventricular thrombus in six, left ventricular aneurysm in three and one each with mitral valve endocarditis and global myocardial dysfunction. Only the mitral valve findings were expected on the basis of a previous M-mode echocardiographic study carried out in our city on healthy elderly volunteers.From the clinical history and all cardiac investigations, we found 59 patients (32%) with a possible cardiac source for cerebral emboli. After cerebral angiography, 29 of these 59 patients also showed a vascular lesion in the appropriate carotid artery and we could not decide definitely which lesion was responsible for the cerebral embolus. In the remaining 30 patients (16.4%), the evidence implicated the heart as the most likely source. These findings illustrate the common coincidence of cardiac and arterial lesions and the difficulties of diagnosing cardiac embolism confidently.Arrhythmia monitoring and 2-D echocardiography detected a previously unrecognized possible cardiac source for emboli in 28 patients (15.2%). The specific identification of potentially treatable conditions by these investigations suggests that they are valuable in arriving at therapeutic decisions for TIA and stroke patients.

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