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TRANSESOPHAGEAL ECHO FOR ALL STROKE PATIENTS?

Identifying which strokes are due to cardiovascular embolic sources can be difficult. Researchers at Johns Hopkins used a mathematical model to compare the cost-effectiveness of nine strategies -- anticoagulating all patients; anticoagulating no patients; and anticoagulation after identification of atrial thrombus by various combinations of cardiac history, transthoracic echocardiography (TTE), and transesophageal echocardiography (TEE). The model assumed that patients were adults, in normal sinus rhythm, and had stroke with no obvious cause.

Strategies including TEE identified the most atrial thrombi, while strategies including no imaging identified none. Anticoagulating all patients was the most costly and least effective strategy due to the high concomitant incidence of intracranial hemorrhage. TEE for all and TEE only for patients with left ventricular dysfunction or valvular heart disease were the most cost-effective strategies ($9,000 and $13,000 per quality-adjusted life-year for the two strategies, respectively). Transthoracic echo was not a component of any of the most cost-effective strategies in this analysis.

Comment: This model is limited by its reliance on data from atrial fibrillation patients, by not incorporating the clinical stroke history, and by uncertainty about the benefits and risks of anticoagulation in this population. If the assumptions are confirmed by future data, this analysis would support a greater role for TEE in guiding the anticoagulation decision in stroke.

— R Saitz

Published in Journal Watch General Medicine December 2, 1997

Citation(s):

McNamara RL et al. Echocardiographic identification of cardiovascular sources of emboli to guide clinical management of stroke: A cost-effectiveness analysis. Ann Intern Med 1997 Nov 1 127 775-787.

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