Patient experience has become a major component of the Center for Medicare and Medicaid Services Value‐Based Purchasing initiative.[1] Hospitals have therefore focused quality improvement (QI) efforts on this area.[2] Hospital performance in the realm of patient experience is generally determined using systematic surveys with closed‐ended questions, but patient‐generated narrative feedback can help hospitals identify the components of care that contribute to patient satisfaction and or are in need of improvement.[3] Online narrative responses posted by patients on rating websites or social media have been criticized because they may not be representative of the population,[4] but they also have some advantages.[5] Any patient may leave a comment, not just those who are selected for a survey. Patients may also experience benefits through the act of sharing their story with others. Moreover, most US hospitals use some form of social media,[6] which they can theoretically use to self‐collect narrative data online. To realize the full potential of patient‐generated online narratives, we need a clearer understanding of the best practices for collecting and using these narratives. We therefore solicited patient feedback on the Facebook page of a large tertiary academic medical center to determine whether it is feasible to use social media platforms for learning about and improving hospital quality.

METHODS

Baystate Medical Center (BMC) is a tertiary care medical center in western Massachusetts. We identified key BMC stakeholders in the areas of QI and public affairs. Noting that patients have expressed interest in leaving comments via social media,[7] the group opted to perform a pilot study to obtain patient narratives via a Facebook prompt (Facebook is a social media site used by an estimated 58% of US adults[8]). The BMC public affairs department delivered a press release to the local media describing a 3‐week period during which patients were invited to leave narrative feedback on the BMC Facebook wall. The BMC Institutional Review Board deemed that this study did not constitute human subjects research.

During March 2014 (March 10, 2014March 24, 2014), we posted (once a week) an open‐ended prompt on BMC's Facebook wall. The prompt was designed to elicit novel descriptions of patient experience that could help to drive QI. It read: We want to hear about your experiences. In the comment section below, please tell us what we do well and how we can improve your care. Because of concerns about the potential reputational risks of allowing open feedback on a public social media page, the prompt also reminded patients of the social media ground rules: there should be no mention of specific physicians, nurses, or other caregivers by name (for liability reasons); and patients should not include details about their medical history (for privacy reasons).

We collected all posts to preserve comments and used directed qualitative content analysis to examine them.[9] Two research team members[3, 10, 11] independently coded the responses. Starting with an a priori codebook that was developed during a previous study,[3] they amended the codebook through an iterative process to incorporate new concepts. After independently coding all blocks of text, the coders reviewed their coding selections and resolved discrepancies through discussion. We then performed second‐level coding, in which codes were organized into major pertinent themes. We reviewed the coded text after applying secondary codes in order to check for accuracy of coding and theme assignment as well as completeness of second‐level coding. We calculated percent agreement, defined as both raters scoring a block of text with the same code divided by total number of codes. We also calculated the Spearman correlation between the 2 reviewers. We used descriptive statistics to assess the frequency of select codes and themes (see Supporting Information, Appendix 1 and Appendix 2, in the online version of this article).[9, 12, 13]

RESULTS

Over a 3‐week study period, 47 comments were submitted by 37 respondents. This yielded 148 codable statements (Table 1). Despite limited information on respondents, we ascertained from Facebook that 32 (86%) were women and 5 (14%) were men.

From coded text, several broad themes were identified (see Table 1 for representative quotes): (1) comments about staff (17/37 respondents, 45.9%). These included positive descriptions of efficiency, caring behavior, good training, and good communication, whereas negative comments included descriptions of unfriendliness, apparent lack of caring, inattentiveness, poor training, unprofessional behavior, and poor communication; (2) comments about specific departments (22/37, 59.5%); (3) comments on technical aspects of care, including perceived errors, incorrect diagnoses, and inattention to pain control (9/37, 24.3%); and (4) comments describing the hospital physical plant, parking, and amenities (9/37, 24.3%). There were a few miscellaneous comments that did not fit into these broad themes, such as expressions of gratitude for our solicitation of narratives. Percent agreement between coders was 80% and Spearman's Rho was 0.82 (p0.001).

A small number (n=3) of respondents repeatedly made comments over the 3‐week period, accounting for 30% (45/148) of codes. These repetitive commenters tended to dominate the Facebook conversation, at times describing the same experience more than once.

DISCUSSION

In this study evaluating the potential utility of social media as a hospital QI tool, several broad themes emerged. From these themes, we identified several areas that could be deemed as QI targets, including: training staff to be more responsive and sensitive to patients needs and concerns, improving patient and visitor parking, and reducing emergency department waiting times. However, the insight gained from solicited Facebook comments was similar to feedback gained from more traditional approaches of soliciting patient perspectives on care, such as patient experience surveys.[14]

Our findings should be viewed in the context of prior work focused on patient narratives in healthcare. Greaves et al. used sentiment analysis to describe the content of nearly 200,000 tweets (comments posted on the social networking website Twitter) sent to National Health Service (NHS) hospitals.[15] Themes were similar to those found in our study: (1) interaction with staff, (2) environment and facilities, and (3) issues of access and timeliness of service. Notably, these themes mirrored prior work examining narratives at NHS hospitals[3] and were similar to domains of commonly used surveys of patient experience.[14] The authors noted that there were issues with the signal to noise ratio (only about 10% of tweets were about quality) and the enforced brevity of Twitter (tweets must be 140 characters or less). These limitations suggest that using Twitter to identify QI targets would be difficult.

In contrast to Greaves et al., we chose to solicit feedback on our hospital's Facebook page. Facebook does not have Twitter's enforced brevity, allowing for more detailed narratives. In addition, we did not encounter the signal‐to‐noise problem, because our prompt was designed to request feedback that was relevant to recent experiences of care. However, a few respondents dominated the conversation, supporting the hypothesis that those most likely to comment may be the patients or families who have had the best or worst experiences. In the future, we will attempt to address this limitation and reduce the influence of repeat commenters by changing our prompt (eg, Please tell us about your experience, but please do not post descriptions of the same experience more than once.).

This pilot demonstrated some of the previously described benefits of online narratives.[5] First, there appears to be value in allowing patients to share their experiences and to read the experiences of others (as indicated in a few grateful patients comments). Second, soliciting online narratives offers a way for hospitals to demonstrate a commitment to transparency. Third, in contrast to closed‐ended survey questions, narrative comments help to identify why patients were satisfied or unsatisfied with their care. Although some surveys with closed‐ended questions also allow for narratives, these comments may or may not be carefully reviewed by the hospital. Using social media to solicit and respond to comments enhances existing methods for evaluating patient experience by engaging patients in a public space, which increases the likelihood that hospitals will attempt to improve care in response.

Notably, none of the identified areas for improvement could be considered novel QI targets for BMC. For example, our hospital has been very focused on training staff around patient experience, and emergency department wait times are the focus of a system‐wide improvement effort called Patient Progress.

This study has other limitations. We conducted this study over a 3‐week time period in a single center and on a single social media site whose members may not be representative of the overall patient population at BMC. Although we do not know how generalizable our findings are (in terms of identifying QI targets), we feel that we have demonstrated how using social media to collect data on patient experience is feasible and could be informative for other hospitals in other locations. It is possible that we did not allow the experiment to run long enough; a longer time or broader outreach (eg, a handout given to every discharged patient over a longer period) may be needed to allow patients adequate opportunity to comment. Of note, we did not specifically examine responses by time period, but it does seem, in post hoc analysis, that after 2 weeks of data collection we reached theoretical saturation with no new themes emerging in the third week (eg, third‐week comments included I heart your nurses. and Love Baystate but hate the ER.). More work is also needed that includes a broader range of social media platforms and more participating hospitals.

In conclusion, the opportunity to provide feedback on Facebook has the potential to engage and empower patients, and hospitals can use these online narratives to help to drive improvement efforts. Yet potential benefits must be weighed against reputational risks, a lack of representative respondents, and the paucity of novel QI targets obtained in this study.

Disclosures: Dr. Lagu is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K01HL114745. The authors report no conflicts of interest.

Patient experience has become a major component of the Center for Medicare and Medicaid Services Value‐Based Purchasing initiative.[1] Hospitals have therefore focused quality improvement (QI) efforts on this area.[2] Hospital performance in the realm of patient experience is generally determined using systematic surveys with closed‐ended questions, but patient‐generated narrative feedback can help hospitals identify the components of care that contribute to patient satisfaction and or are in need of improvement.[3] Online narrative responses posted by patients on rating websites or social media have been criticized because they may not be representative of the population,[4] but they also have some advantages.[5] Any patient may leave a comment, not just those who are selected for a survey. Patients may also experience benefits through the act of sharing their story with others. Moreover, most US hospitals use some form of social media,[6] which they can theoretically use to self‐collect narrative data online. To realize the full potential of patient‐generated online narratives, we need a clearer understanding of the best practices for collecting and using these narratives. We therefore solicited patient feedback on the Facebook page of a large tertiary academic medical center to determine whether it is feasible to use social media platforms for learning about and improving hospital quality.

METHODS

Baystate Medical Center (BMC) is a tertiary care medical center in western Massachusetts. We identified key BMC stakeholders in the areas of QI and public affairs. Noting that patients have expressed interest in leaving comments via social media,[7] the group opted to perform a pilot study to obtain patient narratives via a Facebook prompt (Facebook is a social media site used by an estimated 58% of US adults[8]). The BMC public affairs department delivered a press release to the local media describing a 3‐week period during which patients were invited to leave narrative feedback on the BMC Facebook wall. The BMC Institutional Review Board deemed that this study did not constitute human subjects research.

During March 2014 (March 10, 2014March 24, 2014), we posted (once a week) an open‐ended prompt on BMC's Facebook wall. The prompt was designed to elicit novel descriptions of patient experience that could help to drive QI. It read: We want to hear about your experiences. In the comment section below, please tell us what we do well and how we can improve your care. Because of concerns about the potential reputational risks of allowing open feedback on a public social media page, the prompt also reminded patients of the social media ground rules: there should be no mention of specific physicians, nurses, or other caregivers by name (for liability reasons); and patients should not include details about their medical history (for privacy reasons).

We collected all posts to preserve comments and used directed qualitative content analysis to examine them.[9] Two research team members[3, 10, 11] independently coded the responses. Starting with an a priori codebook that was developed during a previous study,[3] they amended the codebook through an iterative process to incorporate new concepts. After independently coding all blocks of text, the coders reviewed their coding selections and resolved discrepancies through discussion. We then performed second‐level coding, in which codes were organized into major pertinent themes. We reviewed the coded text after applying secondary codes in order to check for accuracy of coding and theme assignment as well as completeness of second‐level coding. We calculated percent agreement, defined as both raters scoring a block of text with the same code divided by total number of codes. We also calculated the Spearman correlation between the 2 reviewers. We used descriptive statistics to assess the frequency of select codes and themes (see Supporting Information, Appendix 1 and Appendix 2, in the online version of this article).[9, 12, 13]

RESULTS

Over a 3‐week study period, 47 comments were submitted by 37 respondents. This yielded 148 codable statements (Table 1). Despite limited information on respondents, we ascertained from Facebook that 32 (86%) were women and 5 (14%) were men.

From coded text, several broad themes were identified (see Table 1 for representative quotes): (1) comments about staff (17/37 respondents, 45.9%). These included positive descriptions of efficiency, caring behavior, good training, and good communication, whereas negative comments included descriptions of unfriendliness, apparent lack of caring, inattentiveness, poor training, unprofessional behavior, and poor communication; (2) comments about specific departments (22/37, 59.5%); (3) comments on technical aspects of care, including perceived errors, incorrect diagnoses, and inattention to pain control (9/37, 24.3%); and (4) comments describing the hospital physical plant, parking, and amenities (9/37, 24.3%). There were a few miscellaneous comments that did not fit into these broad themes, such as expressions of gratitude for our solicitation of narratives. Percent agreement between coders was 80% and Spearman's Rho was 0.82 (p0.001).

A small number (n=3) of respondents repeatedly made comments over the 3‐week period, accounting for 30% (45/148) of codes. These repetitive commenters tended to dominate the Facebook conversation, at times describing the same experience more than once.

DISCUSSION

In this study evaluating the potential utility of social media as a hospital QI tool, several broad themes emerged. From these themes, we identified several areas that could be deemed as QI targets, including: training staff to be more responsive and sensitive to patients needs and concerns, improving patient and visitor parking, and reducing emergency department waiting times. However, the insight gained from solicited Facebook comments was similar to feedback gained from more traditional approaches of soliciting patient perspectives on care, such as patient experience surveys.[14]

Our findings should be viewed in the context of prior work focused on patient narratives in healthcare. Greaves et al. used sentiment analysis to describe the content of nearly 200,000 tweets (comments posted on the social networking website Twitter) sent to National Health Service (NHS) hospitals.[15] Themes were similar to those found in our study: (1) interaction with staff, (2) environment and facilities, and (3) issues of access and timeliness of service. Notably, these themes mirrored prior work examining narratives at NHS hospitals[3] and were similar to domains of commonly used surveys of patient experience.[14] The authors noted that there were issues with the signal to noise ratio (only about 10% of tweets were about quality) and the enforced brevity of Twitter (tweets must be 140 characters or less). These limitations suggest that using Twitter to identify QI targets would be difficult.

In contrast to Greaves et al., we chose to solicit feedback on our hospital's Facebook page. Facebook does not have Twitter's enforced brevity, allowing for more detailed narratives. In addition, we did not encounter the signal‐to‐noise problem, because our prompt was designed to request feedback that was relevant to recent experiences of care. However, a few respondents dominated the conversation, supporting the hypothesis that those most likely to comment may be the patients or families who have had the best or worst experiences. In the future, we will attempt to address this limitation and reduce the influence of repeat commenters by changing our prompt (eg, Please tell us about your experience, but please do not post descriptions of the same experience more than once.).

This pilot demonstrated some of the previously described benefits of online narratives.[5] First, there appears to be value in allowing patients to share their experiences and to read the experiences of others (as indicated in a few grateful patients comments). Second, soliciting online narratives offers a way for hospitals to demonstrate a commitment to transparency. Third, in contrast to closed‐ended survey questions, narrative comments help to identify why patients were satisfied or unsatisfied with their care. Although some surveys with closed‐ended questions also allow for narratives, these comments may or may not be carefully reviewed by the hospital. Using social media to solicit and respond to comments enhances existing methods for evaluating patient experience by engaging patients in a public space, which increases the likelihood that hospitals will attempt to improve care in response.

Notably, none of the identified areas for improvement could be considered novel QI targets for BMC. For example, our hospital has been very focused on training staff around patient experience, and emergency department wait times are the focus of a system‐wide improvement effort called Patient Progress.

This study has other limitations. We conducted this study over a 3‐week time period in a single center and on a single social media site whose members may not be representative of the overall patient population at BMC. Although we do not know how generalizable our findings are (in terms of identifying QI targets), we feel that we have demonstrated how using social media to collect data on patient experience is feasible and could be informative for other hospitals in other locations. It is possible that we did not allow the experiment to run long enough; a longer time or broader outreach (eg, a handout given to every discharged patient over a longer period) may be needed to allow patients adequate opportunity to comment. Of note, we did not specifically examine responses by time period, but it does seem, in post hoc analysis, that after 2 weeks of data collection we reached theoretical saturation with no new themes emerging in the third week (eg, third‐week comments included I heart your nurses. and Love Baystate but hate the ER.). More work is also needed that includes a broader range of social media platforms and more participating hospitals.

In conclusion, the opportunity to provide feedback on Facebook has the potential to engage and empower patients, and hospitals can use these online narratives to help to drive improvement efforts. Yet potential benefits must be weighed against reputational risks, a lack of representative respondents, and the paucity of novel QI targets obtained in this study.

Disclosures: Dr. Lagu is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K01HL114745. The authors report no conflicts of interest.

Patient experience has become a major component of the Center for Medicare and Medicaid Services Value‐Based Purchasing initiative.[1] Hospitals have therefore focused quality improvement (QI) efforts on this area.[2] Hospital performance in the realm of patient experience is generally determined using systematic surveys with closed‐ended questions, but patient‐generated narrative feedback can help hospitals identify the components of care that contribute to patient satisfaction and or are in need of improvement.[3] Online narrative responses posted by patients on rating websites or social media have been criticized because they may not be representative of the population,[4] but they also have some advantages.[5] Any patient may leave a comment, not just those who are selected for a survey. Patients may also experience benefits through the act of sharing their story with others. Moreover, most US hospitals use some form of social media,[6] which they can theoretically use to self‐collect narrative data online. To realize the full potential of patient‐generated online narratives, we need a clearer understanding of the best practices for collecting and using these narratives. We therefore solicited patient feedback on the Facebook page of a large tertiary academic medical center to determine whether it is feasible to use social media platforms for learning about and improving hospital quality.

METHODS

Baystate Medical Center (BMC) is a tertiary care medical center in western Massachusetts. We identified key BMC stakeholders in the areas of QI and public affairs. Noting that patients have expressed interest in leaving comments via social media,[7] the group opted to perform a pilot study to obtain patient narratives via a Facebook prompt (Facebook is a social media site used by an estimated 58% of US adults[8]). The BMC public affairs department delivered a press release to the local media describing a 3‐week period during which patients were invited to leave narrative feedback on the BMC Facebook wall. The BMC Institutional Review Board deemed that this study did not constitute human subjects research.

During March 2014 (March 10, 2014March 24, 2014), we posted (once a week) an open‐ended prompt on BMC's Facebook wall. The prompt was designed to elicit novel descriptions of patient experience that could help to drive QI. It read: We want to hear about your experiences. In the comment section below, please tell us what we do well and how we can improve your care. Because of concerns about the potential reputational risks of allowing open feedback on a public social media page, the prompt also reminded patients of the social media ground rules: there should be no mention of specific physicians, nurses, or other caregivers by name (for liability reasons); and patients should not include details about their medical history (for privacy reasons).

We collected all posts to preserve comments and used directed qualitative content analysis to examine them.[9] Two research team members[3, 10, 11] independently coded the responses. Starting with an a priori codebook that was developed during a previous study,[3] they amended the codebook through an iterative process to incorporate new concepts. After independently coding all blocks of text, the coders reviewed their coding selections and resolved discrepancies through discussion. We then performed second‐level coding, in which codes were organized into major pertinent themes. We reviewed the coded text after applying secondary codes in order to check for accuracy of coding and theme assignment as well as completeness of second‐level coding. We calculated percent agreement, defined as both raters scoring a block of text with the same code divided by total number of codes. We also calculated the Spearman correlation between the 2 reviewers. We used descriptive statistics to assess the frequency of select codes and themes (see Supporting Information, Appendix 1 and Appendix 2, in the online version of this article).[9, 12, 13]

RESULTS

Over a 3‐week study period, 47 comments were submitted by 37 respondents. This yielded 148 codable statements (Table 1). Despite limited information on respondents, we ascertained from Facebook that 32 (86%) were women and 5 (14%) were men.

From coded text, several broad themes were identified (see Table 1 for representative quotes): (1) comments about staff (17/37 respondents, 45.9%). These included positive descriptions of efficiency, caring behavior, good training, and good communication, whereas negative comments included descriptions of unfriendliness, apparent lack of caring, inattentiveness, poor training, unprofessional behavior, and poor communication; (2) comments about specific departments (22/37, 59.5%); (3) comments on technical aspects of care, including perceived errors, incorrect diagnoses, and inattention to pain control (9/37, 24.3%); and (4) comments describing the hospital physical plant, parking, and amenities (9/37, 24.3%). There were a few miscellaneous comments that did not fit into these broad themes, such as expressions of gratitude for our solicitation of narratives. Percent agreement between coders was 80% and Spearman's Rho was 0.82 (p0.001).

A small number (n=3) of respondents repeatedly made comments over the 3‐week period, accounting for 30% (45/148) of codes. These repetitive commenters tended to dominate the Facebook conversation, at times describing the same experience more than once.

DISCUSSION

In this study evaluating the potential utility of social media as a hospital QI tool, several broad themes emerged. From these themes, we identified several areas that could be deemed as QI targets, including: training staff to be more responsive and sensitive to patients needs and concerns, improving patient and visitor parking, and reducing emergency department waiting times. However, the insight gained from solicited Facebook comments was similar to feedback gained from more traditional approaches of soliciting patient perspectives on care, such as patient experience surveys.[14]

Our findings should be viewed in the context of prior work focused on patient narratives in healthcare. Greaves et al. used sentiment analysis to describe the content of nearly 200,000 tweets (comments posted on the social networking website Twitter) sent to National Health Service (NHS) hospitals.[15] Themes were similar to those found in our study: (1) interaction with staff, (2) environment and facilities, and (3) issues of access and timeliness of service. Notably, these themes mirrored prior work examining narratives at NHS hospitals[3] and were similar to domains of commonly used surveys of patient experience.[14] The authors noted that there were issues with the signal to noise ratio (only about 10% of tweets were about quality) and the enforced brevity of Twitter (tweets must be 140 characters or less). These limitations suggest that using Twitter to identify QI targets would be difficult.

In contrast to Greaves et al., we chose to solicit feedback on our hospital's Facebook page. Facebook does not have Twitter's enforced brevity, allowing for more detailed narratives. In addition, we did not encounter the signal‐to‐noise problem, because our prompt was designed to request feedback that was relevant to recent experiences of care. However, a few respondents dominated the conversation, supporting the hypothesis that those most likely to comment may be the patients or families who have had the best or worst experiences. In the future, we will attempt to address this limitation and reduce the influence of repeat commenters by changing our prompt (eg, Please tell us about your experience, but please do not post descriptions of the same experience more than once.).

This pilot demonstrated some of the previously described benefits of online narratives.[5] First, there appears to be value in allowing patients to share their experiences and to read the experiences of others (as indicated in a few grateful patients comments). Second, soliciting online narratives offers a way for hospitals to demonstrate a commitment to transparency. Third, in contrast to closed‐ended survey questions, narrative comments help to identify why patients were satisfied or unsatisfied with their care. Although some surveys with closed‐ended questions also allow for narratives, these comments may or may not be carefully reviewed by the hospital. Using social media to solicit and respond to comments enhances existing methods for evaluating patient experience by engaging patients in a public space, which increases the likelihood that hospitals will attempt to improve care in response.

Notably, none of the identified areas for improvement could be considered novel QI targets for BMC. For example, our hospital has been very focused on training staff around patient experience, and emergency department wait times are the focus of a system‐wide improvement effort called Patient Progress.

This study has other limitations. We conducted this study over a 3‐week time period in a single center and on a single social media site whose members may not be representative of the overall patient population at BMC. Although we do not know how generalizable our findings are (in terms of identifying QI targets), we feel that we have demonstrated how using social media to collect data on patient experience is feasible and could be informative for other hospitals in other locations. It is possible that we did not allow the experiment to run long enough; a longer time or broader outreach (eg, a handout given to every discharged patient over a longer period) may be needed to allow patients adequate opportunity to comment. Of note, we did not specifically examine responses by time period, but it does seem, in post hoc analysis, that after 2 weeks of data collection we reached theoretical saturation with no new themes emerging in the third week (eg, third‐week comments included I heart your nurses. and Love Baystate but hate the ER.). More work is also needed that includes a broader range of social media platforms and more participating hospitals.

In conclusion, the opportunity to provide feedback on Facebook has the potential to engage and empower patients, and hospitals can use these online narratives to help to drive improvement efforts. Yet potential benefits must be weighed against reputational risks, a lack of representative respondents, and the paucity of novel QI targets obtained in this study.

Disclosures: Dr. Lagu is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K01HL114745. The authors report no conflicts of interest.

After entertaining the possibility of acute intervention, the majority of hospitalists efforts in the management of patients with ischemic stroke involve identifying an etiology and initiating secondary prevention strategies. Other than evaluating stroke risk factors, workup has traditionally involved extracranial and intracranial vessel imaging, cardiac telemetry, and echocardiography. Even after exhaustive searches, no cause for stroke is found in nearly 25% of cases, leading to a recent focus on determining why these so‐called cryptogenic strokes happen and how to prevent their recurrence.[1, 2]

Echocardiography is commonly obtained in most patients with ischemic stroke, but its yield is probably modest at best. Although transesophageal echocardiography (TEE) may be superior to transthoracic echocardiography (TTE) for determining an etiology of stroke, whether these findings substantially change management remains debatable.[3, 4] In this issue of the Journal of Hospital Medicine, Marino and colleagues examined the yield of TEE in patients without a known cause of ischemic stroke following a normal TTE.[5] A possible cause of stroke was identified in 42%, including aortic plaques and patent foramen ovale (PFO), but in only 1 patient did this discovery change management.

Secondary prevention strategies in ischemic stroke outside of atrial fibrillation now almost exclusively involve antiplatelet medications.[6] Studies of secondary prevention in aortic arch atheromas, patients with depressed systolic function, and those with PFO have failed to demonstrate any strategy that is superior to antiplatelets, and therefore the bar is high to show that any TEE findings impact treatment other than obvious and rare smoking guns such as a rare valvular lesion, cardiac tumor, or atrial thrombus.[7, 8, 9]

What is more of a recent headline in stroke workup is the increasing emphasis on long‐term cardiac monitoring following discharge to detect those with atrial fibrillation, which likely comprise between 15% and 20% of cryptogenic stroke patients.[10] Finding atrial fibrillation clearly changes management and therefore has a higher yield than the vast majority of possible findings on echocardiography. Perhaps in patients in whom a TEE is being considered, extended monitoring should happen first as an outpatient, followed by TEE if the stroke etiology remains obscure. On the other hand, severe left atrial enlargement, thrombus in the atrium, or atrial spontaneous echo contrast (smoke) are features on echocardiography that might raise the suspicion of atrial fibrillation so high that anticoagulation could be considered while long‐term monitoring is being used to definitively prove an atrial arrhythmia.

The current study does have some limitations other than those inherent to its retrospective design. Patients were only included if they were older than 50 years. Some have advocated using TEE as the echocardiogram of choice in young stroke patients due to its perhaps higher yield in these individuals; this study does not address this strategy. At institutions such as ours, an abnormal TTE in a cryptogenic stroke patient is followed by a TEE, and this study again does not alter this approach, because only those with a normal TTE were included. The definition of a normal TTE used in the study was so narrow, including normal left ventricular systolic function, that a majority of stroke patients with vascular risk factors such as hypertension would have likely been excluded. Determining what features and quality of a TTE are so definitive that a TEE is not necessary will be an important thrust of additional research. However, because TEE shows a better view of the left atrial appendage, the aortic arch, and is probably a better shunt study compared with TTE, it is not clear if a normal TTE will ever be adequate to prevent this second more invasive study in selected patients.

At the heart of the matter for health systems is the cost‐effectiveness of any screening approach used to determine the etiology of acute ischemic stroke. Studies are underway that will likely demonstrate that long‐term monitoring for atrial fibrillation will be worth it. Although it is dubious that TEE would ever fall into the same category due to its low yield, one might imagine a scenario, as our workup for cryptogenic stroke becomes more and more complicated, where obtaining a TEE is cost‐effective simply because it gives an answer and therefore can halt further testing. Perhaps at the end of the day, a TEE will just allow us to say to our stroke patients that enough is enough.

Disclosures: Dr. Josephson receives personal compensation as Editor‐in‐Chief of the New England Journal of Medicine Journal Watch Neurology and in an editorial capacity for Continuum Audio.

After entertaining the possibility of acute intervention, the majority of hospitalists efforts in the management of patients with ischemic stroke involve identifying an etiology and initiating secondary prevention strategies. Other than evaluating stroke risk factors, workup has traditionally involved extracranial and intracranial vessel imaging, cardiac telemetry, and echocardiography. Even after exhaustive searches, no cause for stroke is found in nearly 25% of cases, leading to a recent focus on determining why these so‐called cryptogenic strokes happen and how to prevent their recurrence.[1, 2]

Echocardiography is commonly obtained in most patients with ischemic stroke, but its yield is probably modest at best. Although transesophageal echocardiography (TEE) may be superior to transthoracic echocardiography (TTE) for determining an etiology of stroke, whether these findings substantially change management remains debatable.[3, 4] In this issue of the Journal of Hospital Medicine, Marino and colleagues examined the yield of TEE in patients without a known cause of ischemic stroke following a normal TTE.[5] A possible cause of stroke was identified in 42%, including aortic plaques and patent foramen ovale (PFO), but in only 1 patient did this discovery change management.

Secondary prevention strategies in ischemic stroke outside of atrial fibrillation now almost exclusively involve antiplatelet medications.[6] Studies of secondary prevention in aortic arch atheromas, patients with depressed systolic function, and those with PFO have failed to demonstrate any strategy that is superior to antiplatelets, and therefore the bar is high to show that any TEE findings impact treatment other than obvious and rare smoking guns such as a rare valvular lesion, cardiac tumor, or atrial thrombus.[7, 8, 9]

What is more of a recent headline in stroke workup is the increasing emphasis on long‐term cardiac monitoring following discharge to detect those with atrial fibrillation, which likely comprise between 15% and 20% of cryptogenic stroke patients.[10] Finding atrial fibrillation clearly changes management and therefore has a higher yield than the vast majority of possible findings on echocardiography. Perhaps in patients in whom a TEE is being considered, extended monitoring should happen first as an outpatient, followed by TEE if the stroke etiology remains obscure. On the other hand, severe left atrial enlargement, thrombus in the atrium, or atrial spontaneous echo contrast (smoke) are features on echocardiography that might raise the suspicion of atrial fibrillation so high that anticoagulation could be considered while long‐term monitoring is being used to definitively prove an atrial arrhythmia.

The current study does have some limitations other than those inherent to its retrospective design. Patients were only included if they were older than 50 years. Some have advocated using TEE as the echocardiogram of choice in young stroke patients due to its perhaps higher yield in these individuals; this study does not address this strategy. At institutions such as ours, an abnormal TTE in a cryptogenic stroke patient is followed by a TEE, and this study again does not alter this approach, because only those with a normal TTE were included. The definition of a normal TTE used in the study was so narrow, including normal left ventricular systolic function, that a majority of stroke patients with vascular risk factors such as hypertension would have likely been excluded. Determining what features and quality of a TTE are so definitive that a TEE is not necessary will be an important thrust of additional research. However, because TEE shows a better view of the left atrial appendage, the aortic arch, and is probably a better shunt study compared with TTE, it is not clear if a normal TTE will ever be adequate to prevent this second more invasive study in selected patients.

At the heart of the matter for health systems is the cost‐effectiveness of any screening approach used to determine the etiology of acute ischemic stroke. Studies are underway that will likely demonstrate that long‐term monitoring for atrial fibrillation will be worth it. Although it is dubious that TEE would ever fall into the same category due to its low yield, one might imagine a scenario, as our workup for cryptogenic stroke becomes more and more complicated, where obtaining a TEE is cost‐effective simply because it gives an answer and therefore can halt further testing. Perhaps at the end of the day, a TEE will just allow us to say to our stroke patients that enough is enough.

Disclosures: Dr. Josephson receives personal compensation as Editor‐in‐Chief of the New England Journal of Medicine Journal Watch Neurology and in an editorial capacity for Continuum Audio.

After entertaining the possibility of acute intervention, the majority of hospitalists efforts in the management of patients with ischemic stroke involve identifying an etiology and initiating secondary prevention strategies. Other than evaluating stroke risk factors, workup has traditionally involved extracranial and intracranial vessel imaging, cardiac telemetry, and echocardiography. Even after exhaustive searches, no cause for stroke is found in nearly 25% of cases, leading to a recent focus on determining why these so‐called cryptogenic strokes happen and how to prevent their recurrence.[1, 2]

Echocardiography is commonly obtained in most patients with ischemic stroke, but its yield is probably modest at best. Although transesophageal echocardiography (TEE) may be superior to transthoracic echocardiography (TTE) for determining an etiology of stroke, whether these findings substantially change management remains debatable.[3, 4] In this issue of the Journal of Hospital Medicine, Marino and colleagues examined the yield of TEE in patients without a known cause of ischemic stroke following a normal TTE.[5] A possible cause of stroke was identified in 42%, including aortic plaques and patent foramen ovale (PFO), but in only 1 patient did this discovery change management.

Secondary prevention strategies in ischemic stroke outside of atrial fibrillation now almost exclusively involve antiplatelet medications.[6] Studies of secondary prevention in aortic arch atheromas, patients with depressed systolic function, and those with PFO have failed to demonstrate any strategy that is superior to antiplatelets, and therefore the bar is high to show that any TEE findings impact treatment other than obvious and rare smoking guns such as a rare valvular lesion, cardiac tumor, or atrial thrombus.[7, 8, 9]

What is more of a recent headline in stroke workup is the increasing emphasis on long‐term cardiac monitoring following discharge to detect those with atrial fibrillation, which likely comprise between 15% and 20% of cryptogenic stroke patients.[10] Finding atrial fibrillation clearly changes management and therefore has a higher yield than the vast majority of possible findings on echocardiography. Perhaps in patients in whom a TEE is being considered, extended monitoring should happen first as an outpatient, followed by TEE if the stroke etiology remains obscure. On the other hand, severe left atrial enlargement, thrombus in the atrium, or atrial spontaneous echo contrast (smoke) are features on echocardiography that might raise the suspicion of atrial fibrillation so high that anticoagulation could be considered while long‐term monitoring is being used to definitively prove an atrial arrhythmia.

The current study does have some limitations other than those inherent to its retrospective design. Patients were only included if they were older than 50 years. Some have advocated using TEE as the echocardiogram of choice in young stroke patients due to its perhaps higher yield in these individuals; this study does not address this strategy. At institutions such as ours, an abnormal TTE in a cryptogenic stroke patient is followed by a TEE, and this study again does not alter this approach, because only those with a normal TTE were included. The definition of a normal TTE used in the study was so narrow, including normal left ventricular systolic function, that a majority of stroke patients with vascular risk factors such as hypertension would have likely been excluded. Determining what features and quality of a TTE are so definitive that a TEE is not necessary will be an important thrust of additional research. However, because TEE shows a better view of the left atrial appendage, the aortic arch, and is probably a better shunt study compared with TTE, it is not clear if a normal TTE will ever be adequate to prevent this second more invasive study in selected patients.

At the heart of the matter for health systems is the cost‐effectiveness of any screening approach used to determine the etiology of acute ischemic stroke. Studies are underway that will likely demonstrate that long‐term monitoring for atrial fibrillation will be worth it. Although it is dubious that TEE would ever fall into the same category due to its low yield, one might imagine a scenario, as our workup for cryptogenic stroke becomes more and more complicated, where obtaining a TEE is cost‐effective simply because it gives an answer and therefore can halt further testing. Perhaps at the end of the day, a TEE will just allow us to say to our stroke patients that enough is enough.

Disclosures: Dr. Josephson receives personal compensation as Editor‐in‐Chief of the New England Journal of Medicine Journal Watch Neurology and in an editorial capacity for Continuum Audio.

Specific transesophageal echocardiography (TEE) findings associated with stroke include cardiac thrombi (particularly left atrial appendage [LAA]), left atrial spontaneous echo contrast, interatrial septal anomalies (particularly patent foramen ovale [PFO]), and atheromatous disease of the aorta. In younger patients (aged <50 years) with stroke of uncertain etiology, TEE is often recommended because of reported higher yield than transthoracic echocardiogram (TTE), particularly in detecting PFO or atrial septal aneurysm (ASA).[1]

Aside from oral anticoagulation in patients with an intracardiac thrombus, current guidelines and scientific evidence do not support specific therapeutic interventions for the other TEE findings. For example, the most effective therapy for stroke prevention with findings of aortic arch plaque remains uncertain. In addition, the very rare patient presenting with stroke from a cardiac tumor, which is generally visible on TTE, might benefit from surgical removal.[2]

We sought to examine the benefit of performing TEE after a normal TTE in patients over age 50 years admitted with a stroke of uncertain etiology. We hypothesized that there would be minimal change in management based on TEE findings after a normal TTE in older patients hospitalized with an unexplained stroke.

METHODS

Over a 4‐year period from 2009 to 2012, all patients over the age of 50 years admitted to our community‐based teaching hospital with a primary diagnosis of ischemic stroke were identified and retrospectively screened by review of our institutional echocardiography database during this time period. Stroke diagnosis had to be confirmed with acute or subacute ischemia on brain magnetic resonance imaging. Patients with an indication for anticoagulation or who had a known history of atrial fibrillation or flutter were excluded. Patients were monitored with continuous telemetry during hospital admission and were also excluded if they developed atrial fibrillation or flutter after admission. Additionally, patients were excluded if a neurologist‐directed evaluation revealed another etiology for the stroke.

A TTE acquired in all patients was performed according to Intersocietal Commission for the Accreditation of Echocardiography Laboratories standards and included 2‐dimensional, color Doppler, continuous wave, and pulse wave data. Images were obtained in the parasternal long and short axis, apical 4‐chamber, 2‐chamber, and long axis views. An abnormal TTE was defined as a study with a prosthetic valve, abnormal left ventricular (LV) systolic function, an intracardiac mass, intracardiac shunt, or severe valvular heart disease, as these significant findings may explain stroke.

Standardized TEE images were obtained with midesophageal 4‐chamber, mitral commissural, 2‐chamber, long axis, ascending aorta long axis, aortic valve short axis, right ventricular inflow‐outflow, and bicaval views. Detailed multiplanar evaluation of the LAA was performed. If no interatrial shunt was visualized with color flow Doppler in the bicaval view, agitated intravenous saline was administered for further evaluation. Additional standard images were obtained of the descending aorta and aortic arch in the short and long axis. Transgastric images were obtained when feasible or necessary.

The study was submitted to our institutional review board. As no patient identifiers were stored, and we used previously existing data from an institutional echocardiography database to conduct the study, it was determined to be exempt.

Statistical analysis was performed by recording the prevalence of each potential cardiac source of embolism.

RESULTS

Of the 853 consecutive patients screened, 456 were excluded because of atrial fibrillation, atrial flutter, or another etiology of stroke. An additional 134 patients were excluded with an abnormal TTE or if a TEE was not performed. The remaining 263 patients were analyzed based on TEE findings (Figure 1).

Figure 1

The mean age was 66.7 years (range, 5091 years), and 42.5% were female. A possible etiology of stroke (Table 1) discovered included complex plaque of the ascending aorta or arch 44/263 (16.7%), PFO 18/263 (6.8%), atrial septal aneurysm 25/263 (9.5%), and both ASA and PFO in 11/263 (4.2%), and spontaneous contrast was seen in the left atrium or LAA in 13/263 (4.9%) patients. One patient had a thrombus in the LAA for which anticoagulation was prescribed. No other intracardiac masses were identified.

Overall, 42.6% of patients had a TEE finding which could explain the etiology of stroke or transient ischemic attack (TIA), but only 1 patient (0.4%) had a finding that changed therapy. Follow‐up was available at 6 months for 85 patients, and 13 (15%) of these patients had been discovered to develop atrial fibrillation in the interim.

DISCUSSION

Our study retrospectively analyzed the utility of TEE in patients over age 50 years admitted with ischemic stroke without a clear etiology. We found that TEE provides significant incremental diagnostic benefit as compared to TTE in identifying a possible etiology of stroke in these patients. This is consistent with prior studies showing a high diagnostic yield of TEE in patient with ischemic stroke of uncertain etiology.[3] However, in our study, based on current guidelines, virtually none of these findings directly altered patient management.

The 2014 guidelines for secondary stroke prevention recommend antiplatelet and statin therapy (in addition to lifestyle modification, smoking cessation, and blood glucose and blood pressure control) as a standard medical regimen in patients with stroke or TIA of uncertain etiology. The finding of aortic arch atheroma does not warrant supplementary treatment in addition to an antiplatelet and statin according to current guidelines. Atherosclerosis of the aortic arch is an important source of cerebral embolism, particularly in cases where plaque is >4 mm in size.[4] A recent study by Amarenco et al., comparing efficacy of combined antiplatelet therapy (clopidogrel and aspirin) to warfarin in recurrent stroke prevention in patients with >4 mm aortic arch plaque, showed nonsignificant reduction in rate of recurrent stroke with dual antiplatelet therapy.[5] However, optimal therapy for these patients still remains uncertain beyond standard stroke‐prevention treatment. Although there are emerging data on therapeutic options in patients with complex atheroma, there is currently no specific guideline‐recommended therapy or consensus among stroke neurologists. Potentially, if an individual practitioner had a strong feeling on therapeutic modifications based on the presence of complex aortic arch atheroma, the TEE would have value to their patient. However, in our study, which had a prevalence of 16.8% of complex plaque of the ascending aorta or arch, there were no therapeutic changes based on this finding. This reinforces the limited value of this test that we observed in our study population.

Anticoagulation has not been shown to be superior to aspirin in patients with PFO (with or without ASA), and recent studies showed no benefit of procedural PFO closure compared to best medical management for stroke prevention (Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment [RESPECT], Evaluation of the STARFlex Septal Closure System in Patients with a Stroke and/or Transient Ischemic Attack due to Presumed Paradoxical Embolism through a Patent Foramen Ovale [CLOSURE I]).[6, 7] However, a patient with a PFO and deep vein thrombosis would benefit from anticoagulation and consideration of PFO closure.[8] This rare entity could be excluded with a simple lower extremity duplex without the need for a TEE, which does come with a small risk of complications related to anesthesia and local oropharyngeal trauma as well as discomfort to the patient and increased cost. Spontaneous echo contrast is not an independent indication for anticoagulation. If spontaneous contrast were associated with mitral stenosis and an embolic event, then anticoagulation would be indicated.[9] Mitral stenosis is easily diagnosed with TTE.

LAA or left atrial thrombus is the predominant finding exclusive to TEE that would change management for secondary stroke prevention, specifically anticoagulation. Fifteen studies representing over 3000 patients in a 2014 meta‐analysis reported the prevalence of left atrial or LAA thrombus in patients aged 55 years with a cryptogenic stroke to be 4%, with a range in the studies of 0% to 21.2%.[3] The wide range of prevalence of this finding is likely related to the prevalence of known atrial arrhythmias or structural heart disease in the population of patients included in the analysis. Left atrial or LAA thrombus in the absence of systolic dysfunction, severe valve disease, or known atrial fibrillation is exceedingly uncommon (0.3%).[10] It is likely that the few patients with left atrial or LAA thrombus without 1 of these conditions probably has undiagnosed paroxysmal atrial fibrillation. In previous studies that showed a high prevalence of left atrial or LAA thrombus, there was no mention of the presence or absence of LV dysfunction or severe valve disease in patients with left atrial or LAA thrombus. Additionally, these studies only required a 12‐lead electrocardiogram or did not specify the presence or duration of continuous rhythm monitoring.[11, 12, 13, 14] Several of the studies with high incidence of left atrial or LAA thrombus specifically stated that some of these patients were known to have atrial fibrillation.[11, 13]

Approximately 8% of patients admitted with stroke are found to have atrial fibrillation only after admission with continuous electrocardiogram monitoring. The detection rate is nearly half if monitoring is limited to 24 hours instead of several days. Overall, detection rates of atrial fibrillation following stroke are relatively low during initial hospitalization.[15] More intense monitoring for atrial fibrillation in patients with a stroke of uncertain etiology with the use of a subcutaneous implantable cardiac monitor increases the detection rate to 12.4% at 1 year, and increases with longer monitoring time.[16] Therefore, identification of older stroke patients without significant stroke risk factors may be candidates for longer‐term cardiac monitoring to increase yield for detection of atrial fibrillation. Currently, continuous electrocardiographic monitoring of patients for the duration of their hospitalization and up to 30 days afterward is recommended.[8]

Our study differs from prior studies that showed a much higher prevalence of LAA or left atrial thrombus in 2 important ways. Patients with severe valve disease or LV dysfunction were excluded on the basis of TTE. Additionally, our patients underwent continuous electrocardiographic monitoring for the duration of their hospitalization and were excluded with a prior history or newly discovered atrial fibrillation or flutter. Our intention was to examine the value of adding TEE when no other etiology of stroke was identified. Value can be defined as healthcare outcomes achieved per dollar spent. Our study was not designed to look at long‐term outcomes; rather, we used immediate change in patient management as a surrogate.

There are several limitations to our study that must be noted. This was a single‐center study potentially creating a bias as less stringent selection of patients undergoing TEE may be the practice at other institutions. This analysis was retrospective; therefore, there may have been bias as to which patients were selected to undergo TEE. Additionally, stroke subtype was not specified, and the pretest probability of a cardioembolic source differs based on subtype. Last, we focused this study on immediate changes in clinical management prompted by TEE results, and did not assess patient perceptions of TEE value related to enhanced knowledge about the etiology of their stroke; this area represents an opportunity for further research.

CONCLUSIONS

TEE provides a substantial increase in possible explanation of stroke etiology in patients over age 50 years admitted with a stroke of uncertain cause and a normal TTE. However, there is minimal incremental value in regard to change in therapeutic management in these patients. In a time of increased focus on providing cost effective healthcare, our findings suggest that the need for TEE in this stroke population should be more closely examined.

Disclosure: Nothing to report.

Specific transesophageal echocardiography (TEE) findings associated with stroke include cardiac thrombi (particularly left atrial appendage [LAA]), left atrial spontaneous echo contrast, interatrial septal anomalies (particularly patent foramen ovale [PFO]), and atheromatous disease of the aorta. In younger patients (aged <50 years) with stroke of uncertain etiology, TEE is often recommended because of reported higher yield than transthoracic echocardiogram (TTE), particularly in detecting PFO or atrial septal aneurysm (ASA).[1]

Aside from oral anticoagulation in patients with an intracardiac thrombus, current guidelines and scientific evidence do not support specific therapeutic interventions for the other TEE findings. For example, the most effective therapy for stroke prevention with findings of aortic arch plaque remains uncertain. In addition, the very rare patient presenting with stroke from a cardiac tumor, which is generally visible on TTE, might benefit from surgical removal.[2]

We sought to examine the benefit of performing TEE after a normal TTE in patients over age 50 years admitted with a stroke of uncertain etiology. We hypothesized that there would be minimal change in management based on TEE findings after a normal TTE in older patients hospitalized with an unexplained stroke.

METHODS

Over a 4‐year period from 2009 to 2012, all patients over the age of 50 years admitted to our community‐based teaching hospital with a primary diagnosis of ischemic stroke were identified and retrospectively screened by review of our institutional echocardiography database during this time period. Stroke diagnosis had to be confirmed with acute or subacute ischemia on brain magnetic resonance imaging. Patients with an indication for anticoagulation or who had a known history of atrial fibrillation or flutter were excluded. Patients were monitored with continuous telemetry during hospital admission and were also excluded if they developed atrial fibrillation or flutter after admission. Additionally, patients were excluded if a neurologist‐directed evaluation revealed another etiology for the stroke.

A TTE acquired in all patients was performed according to Intersocietal Commission for the Accreditation of Echocardiography Laboratories standards and included 2‐dimensional, color Doppler, continuous wave, and pulse wave data. Images were obtained in the parasternal long and short axis, apical 4‐chamber, 2‐chamber, and long axis views. An abnormal TTE was defined as a study with a prosthetic valve, abnormal left ventricular (LV) systolic function, an intracardiac mass, intracardiac shunt, or severe valvular heart disease, as these significant findings may explain stroke.

Standardized TEE images were obtained with midesophageal 4‐chamber, mitral commissural, 2‐chamber, long axis, ascending aorta long axis, aortic valve short axis, right ventricular inflow‐outflow, and bicaval views. Detailed multiplanar evaluation of the LAA was performed. If no interatrial shunt was visualized with color flow Doppler in the bicaval view, agitated intravenous saline was administered for further evaluation. Additional standard images were obtained of the descending aorta and aortic arch in the short and long axis. Transgastric images were obtained when feasible or necessary.

The study was submitted to our institutional review board. As no patient identifiers were stored, and we used previously existing data from an institutional echocardiography database to conduct the study, it was determined to be exempt.

Statistical analysis was performed by recording the prevalence of each potential cardiac source of embolism.

RESULTS

Of the 853 consecutive patients screened, 456 were excluded because of atrial fibrillation, atrial flutter, or another etiology of stroke. An additional 134 patients were excluded with an abnormal TTE or if a TEE was not performed. The remaining 263 patients were analyzed based on TEE findings (Figure 1).

Figure 1

The mean age was 66.7 years (range, 5091 years), and 42.5% were female. A possible etiology of stroke (Table 1) discovered included complex plaque of the ascending aorta or arch 44/263 (16.7%), PFO 18/263 (6.8%), atrial septal aneurysm 25/263 (9.5%), and both ASA and PFO in 11/263 (4.2%), and spontaneous contrast was seen in the left atrium or LAA in 13/263 (4.9%) patients. One patient had a thrombus in the LAA for which anticoagulation was prescribed. No other intracardiac masses were identified.

Overall, 42.6% of patients had a TEE finding which could explain the etiology of stroke or transient ischemic attack (TIA), but only 1 patient (0.4%) had a finding that changed therapy. Follow‐up was available at 6 months for 85 patients, and 13 (15%) of these patients had been discovered to develop atrial fibrillation in the interim.

DISCUSSION

Our study retrospectively analyzed the utility of TEE in patients over age 50 years admitted with ischemic stroke without a clear etiology. We found that TEE provides significant incremental diagnostic benefit as compared to TTE in identifying a possible etiology of stroke in these patients. This is consistent with prior studies showing a high diagnostic yield of TEE in patient with ischemic stroke of uncertain etiology.[3] However, in our study, based on current guidelines, virtually none of these findings directly altered patient management.

The 2014 guidelines for secondary stroke prevention recommend antiplatelet and statin therapy (in addition to lifestyle modification, smoking cessation, and blood glucose and blood pressure control) as a standard medical regimen in patients with stroke or TIA of uncertain etiology. The finding of aortic arch atheroma does not warrant supplementary treatment in addition to an antiplatelet and statin according to current guidelines. Atherosclerosis of the aortic arch is an important source of cerebral embolism, particularly in cases where plaque is >4 mm in size.[4] A recent study by Amarenco et al., comparing efficacy of combined antiplatelet therapy (clopidogrel and aspirin) to warfarin in recurrent stroke prevention in patients with >4 mm aortic arch plaque, showed nonsignificant reduction in rate of recurrent stroke with dual antiplatelet therapy.[5] However, optimal therapy for these patients still remains uncertain beyond standard stroke‐prevention treatment. Although there are emerging data on therapeutic options in patients with complex atheroma, there is currently no specific guideline‐recommended therapy or consensus among stroke neurologists. Potentially, if an individual practitioner had a strong feeling on therapeutic modifications based on the presence of complex aortic arch atheroma, the TEE would have value to their patient. However, in our study, which had a prevalence of 16.8% of complex plaque of the ascending aorta or arch, there were no therapeutic changes based on this finding. This reinforces the limited value of this test that we observed in our study population.

Anticoagulation has not been shown to be superior to aspirin in patients with PFO (with or without ASA), and recent studies showed no benefit of procedural PFO closure compared to best medical management for stroke prevention (Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment [RESPECT], Evaluation of the STARFlex Septal Closure System in Patients with a Stroke and/or Transient Ischemic Attack due to Presumed Paradoxical Embolism through a Patent Foramen Ovale [CLOSURE I]).[6, 7] However, a patient with a PFO and deep vein thrombosis would benefit from anticoagulation and consideration of PFO closure.[8] This rare entity could be excluded with a simple lower extremity duplex without the need for a TEE, which does come with a small risk of complications related to anesthesia and local oropharyngeal trauma as well as discomfort to the patient and increased cost. Spontaneous echo contrast is not an independent indication for anticoagulation. If spontaneous contrast were associated with mitral stenosis and an embolic event, then anticoagulation would be indicated.[9] Mitral stenosis is easily diagnosed with TTE.

LAA or left atrial thrombus is the predominant finding exclusive to TEE that would change management for secondary stroke prevention, specifically anticoagulation. Fifteen studies representing over 3000 patients in a 2014 meta‐analysis reported the prevalence of left atrial or LAA thrombus in patients aged 55 years with a cryptogenic stroke to be 4%, with a range in the studies of 0% to 21.2%.[3] The wide range of prevalence of this finding is likely related to the prevalence of known atrial arrhythmias or structural heart disease in the population of patients included in the analysis. Left atrial or LAA thrombus in the absence of systolic dysfunction, severe valve disease, or known atrial fibrillation is exceedingly uncommon (0.3%).[10] It is likely that the few patients with left atrial or LAA thrombus without 1 of these conditions probably has undiagnosed paroxysmal atrial fibrillation. In previous studies that showed a high prevalence of left atrial or LAA thrombus, there was no mention of the presence or absence of LV dysfunction or severe valve disease in patients with left atrial or LAA thrombus. Additionally, these studies only required a 12‐lead electrocardiogram or did not specify the presence or duration of continuous rhythm monitoring.[11, 12, 13, 14] Several of the studies with high incidence of left atrial or LAA thrombus specifically stated that some of these patients were known to have atrial fibrillation.[11, 13]

Approximately 8% of patients admitted with stroke are found to have atrial fibrillation only after admission with continuous electrocardiogram monitoring. The detection rate is nearly half if monitoring is limited to 24 hours instead of several days. Overall, detection rates of atrial fibrillation following stroke are relatively low during initial hospitalization.[15] More intense monitoring for atrial fibrillation in patients with a stroke of uncertain etiology with the use of a subcutaneous implantable cardiac monitor increases the detection rate to 12.4% at 1 year, and increases with longer monitoring time.[16] Therefore, identification of older stroke patients without significant stroke risk factors may be candidates for longer‐term cardiac monitoring to increase yield for detection of atrial fibrillation. Currently, continuous electrocardiographic monitoring of patients for the duration of their hospitalization and up to 30 days afterward is recommended.[8]

Our study differs from prior studies that showed a much higher prevalence of LAA or left atrial thrombus in 2 important ways. Patients with severe valve disease or LV dysfunction were excluded on the basis of TTE. Additionally, our patients underwent continuous electrocardiographic monitoring for the duration of their hospitalization and were excluded with a prior history or newly discovered atrial fibrillation or flutter. Our intention was to examine the value of adding TEE when no other etiology of stroke was identified. Value can be defined as healthcare outcomes achieved per dollar spent. Our study was not designed to look at long‐term outcomes; rather, we used immediate change in patient management as a surrogate.

There are several limitations to our study that must be noted. This was a single‐center study potentially creating a bias as less stringent selection of patients undergoing TEE may be the practice at other institutions. This analysis was retrospective; therefore, there may have been bias as to which patients were selected to undergo TEE. Additionally, stroke subtype was not specified, and the pretest probability of a cardioembolic source differs based on subtype. Last, we focused this study on immediate changes in clinical management prompted by TEE results, and did not assess patient perceptions of TEE value related to enhanced knowledge about the etiology of their stroke; this area represents an opportunity for further research.

CONCLUSIONS

TEE provides a substantial increase in possible explanation of stroke etiology in patients over age 50 years admitted with a stroke of uncertain cause and a normal TTE. However, there is minimal incremental value in regard to change in therapeutic management in these patients. In a time of increased focus on providing cost effective healthcare, our findings suggest that the need for TEE in this stroke population should be more closely examined.

Disclosure: Nothing to report.

Specific transesophageal echocardiography (TEE) findings associated with stroke include cardiac thrombi (particularly left atrial appendage [LAA]), left atrial spontaneous echo contrast, interatrial septal anomalies (particularly patent foramen ovale [PFO]), and atheromatous disease of the aorta. In younger patients (aged <50 years) with stroke of uncertain etiology, TEE is often recommended because of reported higher yield than transthoracic echocardiogram (TTE), particularly in detecting PFO or atrial septal aneurysm (ASA).[1]

Aside from oral anticoagulation in patients with an intracardiac thrombus, current guidelines and scientific evidence do not support specific therapeutic interventions for the other TEE findings. For example, the most effective therapy for stroke prevention with findings of aortic arch plaque remains uncertain. In addition, the very rare patient presenting with stroke from a cardiac tumor, which is generally visible on TTE, might benefit from surgical removal.[2]

We sought to examine the benefit of performing TEE after a normal TTE in patients over age 50 years admitted with a stroke of uncertain etiology. We hypothesized that there would be minimal change in management based on TEE findings after a normal TTE in older patients hospitalized with an unexplained stroke.

METHODS

Over a 4‐year period from 2009 to 2012, all patients over the age of 50 years admitted to our community‐based teaching hospital with a primary diagnosis of ischemic stroke were identified and retrospectively screened by review of our institutional echocardiography database during this time period. Stroke diagnosis had to be confirmed with acute or subacute ischemia on brain magnetic resonance imaging. Patients with an indication for anticoagulation or who had a known history of atrial fibrillation or flutter were excluded. Patients were monitored with continuous telemetry during hospital admission and were also excluded if they developed atrial fibrillation or flutter after admission. Additionally, patients were excluded if a neurologist‐directed evaluation revealed another etiology for the stroke.

A TTE acquired in all patients was performed according to Intersocietal Commission for the Accreditation of Echocardiography Laboratories standards and included 2‐dimensional, color Doppler, continuous wave, and pulse wave data. Images were obtained in the parasternal long and short axis, apical 4‐chamber, 2‐chamber, and long axis views. An abnormal TTE was defined as a study with a prosthetic valve, abnormal left ventricular (LV) systolic function, an intracardiac mass, intracardiac shunt, or severe valvular heart disease, as these significant findings may explain stroke.

Standardized TEE images were obtained with midesophageal 4‐chamber, mitral commissural, 2‐chamber, long axis, ascending aorta long axis, aortic valve short axis, right ventricular inflow‐outflow, and bicaval views. Detailed multiplanar evaluation of the LAA was performed. If no interatrial shunt was visualized with color flow Doppler in the bicaval view, agitated intravenous saline was administered for further evaluation. Additional standard images were obtained of the descending aorta and aortic arch in the short and long axis. Transgastric images were obtained when feasible or necessary.

The study was submitted to our institutional review board. As no patient identifiers were stored, and we used previously existing data from an institutional echocardiography database to conduct the study, it was determined to be exempt.

Statistical analysis was performed by recording the prevalence of each potential cardiac source of embolism.

RESULTS

Of the 853 consecutive patients screened, 456 were excluded because of atrial fibrillation, atrial flutter, or another etiology of stroke. An additional 134 patients were excluded with an abnormal TTE or if a TEE was not performed. The remaining 263 patients were analyzed based on TEE findings (Figure 1).

Figure 1

The mean age was 66.7 years (range, 5091 years), and 42.5% were female. A possible etiology of stroke (Table 1) discovered included complex plaque of the ascending aorta or arch 44/263 (16.7%), PFO 18/263 (6.8%), atrial septal aneurysm 25/263 (9.5%), and both ASA and PFO in 11/263 (4.2%), and spontaneous contrast was seen in the left atrium or LAA in 13/263 (4.9%) patients. One patient had a thrombus in the LAA for which anticoagulation was prescribed. No other intracardiac masses were identified.

Overall, 42.6% of patients had a TEE finding which could explain the etiology of stroke or transient ischemic attack (TIA), but only 1 patient (0.4%) had a finding that changed therapy. Follow‐up was available at 6 months for 85 patients, and 13 (15%) of these patients had been discovered to develop atrial fibrillation in the interim.

DISCUSSION

Our study retrospectively analyzed the utility of TEE in patients over age 50 years admitted with ischemic stroke without a clear etiology. We found that TEE provides significant incremental diagnostic benefit as compared to TTE in identifying a possible etiology of stroke in these patients. This is consistent with prior studies showing a high diagnostic yield of TEE in patient with ischemic stroke of uncertain etiology.[3] However, in our study, based on current guidelines, virtually none of these findings directly altered patient management.

The 2014 guidelines for secondary stroke prevention recommend antiplatelet and statin therapy (in addition to lifestyle modification, smoking cessation, and blood glucose and blood pressure control) as a standard medical regimen in patients with stroke or TIA of uncertain etiology. The finding of aortic arch atheroma does not warrant supplementary treatment in addition to an antiplatelet and statin according to current guidelines. Atherosclerosis of the aortic arch is an important source of cerebral embolism, particularly in cases where plaque is >4 mm in size.[4] A recent study by Amarenco et al., comparing efficacy of combined antiplatelet therapy (clopidogrel and aspirin) to warfarin in recurrent stroke prevention in patients with >4 mm aortic arch plaque, showed nonsignificant reduction in rate of recurrent stroke with dual antiplatelet therapy.[5] However, optimal therapy for these patients still remains uncertain beyond standard stroke‐prevention treatment. Although there are emerging data on therapeutic options in patients with complex atheroma, there is currently no specific guideline‐recommended therapy or consensus among stroke neurologists. Potentially, if an individual practitioner had a strong feeling on therapeutic modifications based on the presence of complex aortic arch atheroma, the TEE would have value to their patient. However, in our study, which had a prevalence of 16.8% of complex plaque of the ascending aorta or arch, there were no therapeutic changes based on this finding. This reinforces the limited value of this test that we observed in our study population.

Anticoagulation has not been shown to be superior to aspirin in patients with PFO (with or without ASA), and recent studies showed no benefit of procedural PFO closure compared to best medical management for stroke prevention (Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment [RESPECT], Evaluation of the STARFlex Septal Closure System in Patients with a Stroke and/or Transient Ischemic Attack due to Presumed Paradoxical Embolism through a Patent Foramen Ovale [CLOSURE I]).[6, 7] However, a patient with a PFO and deep vein thrombosis would benefit from anticoagulation and consideration of PFO closure.[8] This rare entity could be excluded with a simple lower extremity duplex without the need for a TEE, which does come with a small risk of complications related to anesthesia and local oropharyngeal trauma as well as discomfort to the patient and increased cost. Spontaneous echo contrast is not an independent indication for anticoagulation. If spontaneous contrast were associated with mitral stenosis and an embolic event, then anticoagulation would be indicated.[9] Mitral stenosis is easily diagnosed with TTE.

LAA or left atrial thrombus is the predominant finding exclusive to TEE that would change management for secondary stroke prevention, specifically anticoagulation. Fifteen studies representing over 3000 patients in a 2014 meta‐analysis reported the prevalence of left atrial or LAA thrombus in patients aged 55 years with a cryptogenic stroke to be 4%, with a range in the studies of 0% to 21.2%.[3] The wide range of prevalence of this finding is likely related to the prevalence of known atrial arrhythmias or structural heart disease in the population of patients included in the analysis. Left atrial or LAA thrombus in the absence of systolic dysfunction, severe valve disease, or known atrial fibrillation is exceedingly uncommon (0.3%).[10] It is likely that the few patients with left atrial or LAA thrombus without 1 of these conditions probably has undiagnosed paroxysmal atrial fibrillation. In previous studies that showed a high prevalence of left atrial or LAA thrombus, there was no mention of the presence or absence of LV dysfunction or severe valve disease in patients with left atrial or LAA thrombus. Additionally, these studies only required a 12‐lead electrocardiogram or did not specify the presence or duration of continuous rhythm monitoring.[11, 12, 13, 14] Several of the studies with high incidence of left atrial or LAA thrombus specifically stated that some of these patients were known to have atrial fibrillation.[11, 13]

Approximately 8% of patients admitted with stroke are found to have atrial fibrillation only after admission with continuous electrocardiogram monitoring. The detection rate is nearly half if monitoring is limited to 24 hours instead of several days. Overall, detection rates of atrial fibrillation following stroke are relatively low during initial hospitalization.[15] More intense monitoring for atrial fibrillation in patients with a stroke of uncertain etiology with the use of a subcutaneous implantable cardiac monitor increases the detection rate to 12.4% at 1 year, and increases with longer monitoring time.[16] Therefore, identification of older stroke patients without significant stroke risk factors may be candidates for longer‐term cardiac monitoring to increase yield for detection of atrial fibrillation. Currently, continuous electrocardiographic monitoring of patients for the duration of their hospitalization and up to 30 days afterward is recommended.[8]

Our study differs from prior studies that showed a much higher prevalence of LAA or left atrial thrombus in 2 important ways. Patients with severe valve disease or LV dysfunction were excluded on the basis of TTE. Additionally, our patients underwent continuous electrocardiographic monitoring for the duration of their hospitalization and were excluded with a prior history or newly discovered atrial fibrillation or flutter. Our intention was to examine the value of adding TEE when no other etiology of stroke was identified. Value can be defined as healthcare outcomes achieved per dollar spent. Our study was not designed to look at long‐term outcomes; rather, we used immediate change in patient management as a surrogate.

There are several limitations to our study that must be noted. This was a single‐center study potentially creating a bias as less stringent selection of patients undergoing TEE may be the practice at other institutions. This analysis was retrospective; therefore, there may have been bias as to which patients were selected to undergo TEE. Additionally, stroke subtype was not specified, and the pretest probability of a cardioembolic source differs based on subtype. Last, we focused this study on immediate changes in clinical management prompted by TEE results, and did not assess patient perceptions of TEE value related to enhanced knowledge about the etiology of their stroke; this area represents an opportunity for further research.

CONCLUSIONS

TEE provides a substantial increase in possible explanation of stroke etiology in patients over age 50 years admitted with a stroke of uncertain cause and a normal TTE. However, there is minimal incremental value in regard to change in therapeutic management in these patients. In a time of increased focus on providing cost effective healthcare, our findings suggest that the need for TEE in this stroke population should be more closely examined.

Disclosure: Nothing to report.