A 67-year-old man with a 30 pack-year history of cigarette smoking, who has hypertension, diabetes, and mild chronic obstructive pulmonary disease presents to the emergency department with left-sided hemiparesis and sensory loss for the past 6 hours.
Physical examination performed in the emergency department reveals a regular heart rhythm with otherwise normal heart sounds. Lungs are clear to auscultation, but left-sided weakness and sensory loss is noted. Lower extremity examination shows trace ankle edema.
Significant laboratory results included a normal brain natriuretic protein level, elevated cardiac troponin level, and no evidence of metabolic disturbance.
An electrocardiogram is ordered and reveals sinus rhythm with deep lateral T-wave inversions. Computed tomography scan of the brain shows a small acute infarct in the territory of the right middle cerebral artery with no evidence of hemorrhage. He is treated with thrombolytics and started on aspirin prior to hospital discharge.
What would be the next best step in the diagnostic workup for this patient?
A. Transthoracic echocardiography to evaluate for thrombus or patent foramen ovale
B. Transesophageal echocardiography to evaluate for thrombus or patent foramen ovale
C. Exercise nuclear myocardial perfusion imaging
D. 24-hour telemetry monitoring followed by 10-day Holter monitoring to evaluate for episodes of atrial fibrillation
E. Cardiac catheterization because of the elevated troponin level and deep T-wave inversions
Answer: D. 24-hour telemetry monitoring followed by 10-day Holter monitoring to evaluate for episodes of atrial fibrillation
One quarter of patients with stroke who are monitored for an extended period of time are found to have atrial fibrillation. In the Find-AF trial, 14% of patients were found to have atrial fibrillation with 10-day Holter monitoring at baseline, at 3 months, and at 6 months vs only 5% of those randomly assigned to standard of care.1
Unfortunately, only a few small studies have looked at prolonged monitoring, and most of these failed to show a significant difference in clinical outcomes. For this reason, prolonged cardiac monitoring carried only a class IIb recommendation in the latest stroke guidelines from the American Heart Association.2
These updated stroke guidelines found that routine echocardiography for secondary prevention in all patients with acute stroke was not cost-effective and often led to as many false-positive results as false-negative results. Thus, transesophageal echocardiography and transthoracic echocardiography are no longer routinely recommended.2
Driving this recommendation is a lack of positive outcomes data for patent foramen ovale closure over antithrombotic therapy alone. Echocardiography continues to carry a class IIb recommendation for select patients at highest risk for intracardiac thrombus.