Ischaemic Stroke and the Echocardiographic "Bubble Study": Are We Screening the Right Patients?

Paul Maggiore, Jamie Bellinge, David Chieng, David White, Nick S R Lan, Biyanka Jaltotage, Umar Ali, Madeleine Gordon, Kevin Chung, Paul Stobie, Justin Ng, Graeme J Hankey, Brendan McQuillan

Research output: Contribution to journalArticle

Abstract

BACKGROUND: Patent foramen ovale (PFO) is a potential mechanism for paradoxical embolism in cryptogenic ischaemic stroke or transient ischaemic attack (TIA). PFO is typically demonstrated with agitated saline ("bubble study", BS) during echocardiography. We hypothesised that the BS is frequently requested in patients that have a readily identifiable cause of stroke, that any PFO detected is likely incidental, and its detection often does not alter management.

METHODS: This was a retrospective observational study of patients with recent ischaemic stroke/TIA referred for a BS. Patient demographics, stroke risk factors, vascular/cerebral imaging results and transoesophageal echocardiogram (TOE) reports were recorded. A "modified" Risk of Paradoxical Embolism (RoPE) score was calculated. Change in management was defined as antiplatelet/anticoagulant therapy alteration or referral for PFO closure. Bubble Study complications were recorded.

RESULTS: Among 715 patients with ischaemic stroke/TIA referred for a BS, 8.7% had atrial fibrillation and 9.2% had carotid stenosis ≥70%. At least three stroke risk factors were present in 39.3% and only 47.1% of patients screened had a "modified" RoPE score of >5. A PFO was detected in 248 patients of whom only 31% (77/248) had a subsequent change in management. Of BS performed, 1/924 patients (0.1%) suffered a TIA as a complication.

CONCLUSIONS: The echocardiographic BS is frequently performed in patients that have a readily identifiable cause of stroke and whose PFO unlikely relates to the stroke/TIA. Bubble Study findings resulted in a change in management in the minority. The procedure is safe but the complication rate warrants informed consent.

Original languageEnglish
Pages (from-to)1183-1189
JournalHeart, Lung & Circulation
Volume28
Issue number8
DOIs
Publication statusPublished - Aug 2018

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Patient Rights
Patent Foramen Ovale
Stroke
Transient Ischemic Attack
Paradoxical Embolism
Carotid Stenosis
Informed Consent
Anticoagulants
Atrial Fibrillation
Observational Studies
Blood Vessels
Echocardiography
Referral and Consultation
Retrospective Studies
Demography

Cite this

Maggiore, Paul ; Bellinge, Jamie ; Chieng, David ; White, David ; Lan, Nick S R ; Jaltotage, Biyanka ; Ali, Umar ; Gordon, Madeleine ; Chung, Kevin ; Stobie, Paul ; Ng, Justin ; Hankey, Graeme J ; McQuillan, Brendan. / Ischaemic Stroke and the Echocardiographic "Bubble Study" : Are We Screening the Right Patients?. In: Heart, Lung & Circulation. 2018 ; Vol. 28, No. 8. pp. 1183-1189.
@article{5d089a90df0a4c32af488af0120f5393,
title = "Ischaemic Stroke and the Echocardiographic {"}Bubble Study{"}: Are We Screening the Right Patients?",
abstract = "BACKGROUND: Patent foramen ovale (PFO) is a potential mechanism for paradoxical embolism in cryptogenic ischaemic stroke or transient ischaemic attack (TIA). PFO is typically demonstrated with agitated saline ({"}bubble study{"}, BS) during echocardiography. We hypothesised that the BS is frequently requested in patients that have a readily identifiable cause of stroke, that any PFO detected is likely incidental, and its detection often does not alter management.METHODS: This was a retrospective observational study of patients with recent ischaemic stroke/TIA referred for a BS. Patient demographics, stroke risk factors, vascular/cerebral imaging results and transoesophageal echocardiogram (TOE) reports were recorded. A {"}modified{"} Risk of Paradoxical Embolism (RoPE) score was calculated. Change in management was defined as antiplatelet/anticoagulant therapy alteration or referral for PFO closure. Bubble Study complications were recorded.RESULTS: Among 715 patients with ischaemic stroke/TIA referred for a BS, 8.7{\%} had atrial fibrillation and 9.2{\%} had carotid stenosis ≥70{\%}. At least three stroke risk factors were present in 39.3{\%} and only 47.1{\%} of patients screened had a {"}modified{"} RoPE score of >5. A PFO was detected in 248 patients of whom only 31{\%} (77/248) had a subsequent change in management. Of BS performed, 1/924 patients (0.1{\%}) suffered a TIA as a complication.CONCLUSIONS: The echocardiographic BS is frequently performed in patients that have a readily identifiable cause of stroke and whose PFO unlikely relates to the stroke/TIA. Bubble Study findings resulted in a change in management in the minority. The procedure is safe but the complication rate warrants informed consent.",
author = "Paul Maggiore and Jamie Bellinge and David Chieng and David White and Lan, {Nick S R} and Biyanka Jaltotage and Umar Ali and Madeleine Gordon and Kevin Chung and Paul Stobie and Justin Ng and Hankey, {Graeme J} and Brendan McQuillan",
note = "Copyright {\circledC} 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). All rights reserved.",
year = "2018",
month = "8",
doi = "10.1016/j.hlc.2018.07.007",
language = "English",
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pages = "1183--1189",
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Maggiore, P, Bellinge, J, Chieng, D, White, D, Lan, NSR, Jaltotage, B, Ali, U, Gordon, M, Chung, K, Stobie, P, Ng, J, Hankey, GJ & McQuillan, B 2018, 'Ischaemic Stroke and the Echocardiographic "Bubble Study": Are We Screening the Right Patients?' Heart, Lung & Circulation, vol. 28, no. 8, pp. 1183-1189. https://doi.org/10.1016/j.hlc.2018.07.007

Ischaemic Stroke and the Echocardiographic "Bubble Study" : Are We Screening the Right Patients? / Maggiore, Paul; Bellinge, Jamie; Chieng, David; White, David; Lan, Nick S R; Jaltotage, Biyanka; Ali, Umar; Gordon, Madeleine; Chung, Kevin; Stobie, Paul; Ng, Justin; Hankey, Graeme J; McQuillan, Brendan.

In: Heart, Lung & Circulation, Vol. 28, No. 8, 08.2018, p. 1183-1189.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Ischaemic Stroke and the Echocardiographic "Bubble Study"

T2 - Are We Screening the Right Patients?

AU - Maggiore, Paul

AU - Bellinge, Jamie

AU - Chieng, David

AU - White, David

AU - Lan, Nick S R

AU - Jaltotage, Biyanka

AU - Ali, Umar

AU - Gordon, Madeleine

AU - Chung, Kevin

AU - Stobie, Paul

AU - Ng, Justin

AU - Hankey, Graeme J

AU - McQuillan, Brendan

N1 - Copyright © 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). All rights reserved.

PY - 2018/8

Y1 - 2018/8

N2 - BACKGROUND: Patent foramen ovale (PFO) is a potential mechanism for paradoxical embolism in cryptogenic ischaemic stroke or transient ischaemic attack (TIA). PFO is typically demonstrated with agitated saline ("bubble study", BS) during echocardiography. We hypothesised that the BS is frequently requested in patients that have a readily identifiable cause of stroke, that any PFO detected is likely incidental, and its detection often does not alter management.METHODS: This was a retrospective observational study of patients with recent ischaemic stroke/TIA referred for a BS. Patient demographics, stroke risk factors, vascular/cerebral imaging results and transoesophageal echocardiogram (TOE) reports were recorded. A "modified" Risk of Paradoxical Embolism (RoPE) score was calculated. Change in management was defined as antiplatelet/anticoagulant therapy alteration or referral for PFO closure. Bubble Study complications were recorded.RESULTS: Among 715 patients with ischaemic stroke/TIA referred for a BS, 8.7% had atrial fibrillation and 9.2% had carotid stenosis ≥70%. At least three stroke risk factors were present in 39.3% and only 47.1% of patients screened had a "modified" RoPE score of >5. A PFO was detected in 248 patients of whom only 31% (77/248) had a subsequent change in management. Of BS performed, 1/924 patients (0.1%) suffered a TIA as a complication.CONCLUSIONS: The echocardiographic BS is frequently performed in patients that have a readily identifiable cause of stroke and whose PFO unlikely relates to the stroke/TIA. Bubble Study findings resulted in a change in management in the minority. The procedure is safe but the complication rate warrants informed consent.

AB - BACKGROUND: Patent foramen ovale (PFO) is a potential mechanism for paradoxical embolism in cryptogenic ischaemic stroke or transient ischaemic attack (TIA). PFO is typically demonstrated with agitated saline ("bubble study", BS) during echocardiography. We hypothesised that the BS is frequently requested in patients that have a readily identifiable cause of stroke, that any PFO detected is likely incidental, and its detection often does not alter management.METHODS: This was a retrospective observational study of patients with recent ischaemic stroke/TIA referred for a BS. Patient demographics, stroke risk factors, vascular/cerebral imaging results and transoesophageal echocardiogram (TOE) reports were recorded. A "modified" Risk of Paradoxical Embolism (RoPE) score was calculated. Change in management was defined as antiplatelet/anticoagulant therapy alteration or referral for PFO closure. Bubble Study complications were recorded.RESULTS: Among 715 patients with ischaemic stroke/TIA referred for a BS, 8.7% had atrial fibrillation and 9.2% had carotid stenosis ≥70%. At least three stroke risk factors were present in 39.3% and only 47.1% of patients screened had a "modified" RoPE score of >5. A PFO was detected in 248 patients of whom only 31% (77/248) had a subsequent change in management. Of BS performed, 1/924 patients (0.1%) suffered a TIA as a complication.CONCLUSIONS: The echocardiographic BS is frequently performed in patients that have a readily identifiable cause of stroke and whose PFO unlikely relates to the stroke/TIA. Bubble Study findings resulted in a change in management in the minority. The procedure is safe but the complication rate warrants informed consent.

U2 - 10.1016/j.hlc.2018.07.007

DO - 10.1016/j.hlc.2018.07.007

M3 - Article

VL - 28

SP - 1183

EP - 1189

JO - Heart, Lung & Circulation

JF - Heart, Lung & Circulation

SN - 1444-2892

IS - 8

ER -