12. Cardiac Evaluation
An electrocardiogram (EKG) should be done to exclude atrial fibrillation and to rule out silent myocardial infarction or ischemia, which may occur as a consequence of the stroke.
If atrial fibrillation or other important arrhythmia is suspected, cardiac telemetry or Holter monitor is needed.An echocardiogram is helpful in looking for a cardioembolic source and right-to-left shunts.
A transthoracic echocardiogram (TTE) can show wall motion abnormalities (anterior wall akinesis carries high embolic risk), low left ventricular ejection fraction (<20–30% generally agreed upon as a cutoff), valvular abnormalities, and a patent foramen ovale (PFO).
Transesophageal echocardiogram (TEE) can show the atria better. Left atrial appendage clot, size of PFO, PFO associated with atrial septal aneurysm, aortic arch atheroma, and spontaneous echo contrast are some of the findings associated with increased risk for ischemic stroke.
Long-term anticoagulation with warfarin is considered to be the best prevention strategy for cardioembolic sources, but for many of the etiologies, it is still controversial whether warfarin is better than antiplatelets.
TCD with bubble contrast is as sensitive as TEE for detection of right-to-left shunt.
Recurrent Stroke Risk Factor Screening
Monitor blood pressure.
- Obtain fasting lipid panel.
- Screen for diabetes.
- Screen for hyperhomocysteinemia (though a risk factor, whether or not screening and therapy are beneficial is controversial).
- Smoking cessation counseling, if applicable.