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Cost-Effectiveness of Echocardiography after Stroke
- James W. Tam, MD, FRCP(C);
- Normand Lazarow, MD, PhD, FRCP(C); and
- Kevin Wolfe, MD, FRCP(C)
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Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
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TO THE EDITOR:
McNamara and colleagues [1] reported on the cost-effectiveness of transesophageal echocardiography (TEE) and the cost advantages over transthoracic echocardiography (TTE) in patients with stroke in normal sinus rhythm. As clinical echocardiographers, we are not as willing to dismiss the role of TTE. In contrast to the 2% to 3% incidence of complications with TEE [2], TTE is not associated with significant adverse reactions. Furthermore, many patients often have a readily identifiable cause apparent on TTE (for example, left ventricular dysfunction, left ventricular thrombus, mitral stenosis), and evidence suggests [3] that newer-generation TTE systems can detect left atrial thrombus with high sensitivity.
In patients with sinus rhythm, absence of clinical heart disease, or normal TTE findings, the incidence of left atrial thrombus is low. In the nine studies selected by McNamara and colleagues that provided this subgroup information (their references 8-14, 17, and 21), only 6 of 736 patients (0.8%) had left atrial thrombus detected by TEE. Of 824 consecutive patients with stroke, peripheral embolism, or transient ischemic attack referred for TEE at the Cleveland Clinic [4], 236 (29%) had sinus rhythm and normal TTE findings; none of these 236 had left atrial thrombus on TEE. Although TEE may be able to identify other associated abnormalities, such as patent foramen ovale or atrial septal aneurysm, more readily than TTE can, the subsequent effect on patient management remains unproven.
We suggest that TTE still be used as the first-line approach. with TEE to follow in a selective fashion (Figure 1). Cost-effectiveness issues require additional formal analysis.
James W. Tam, MD, FRCP(C)
Normand Lazarow, MD, PhD, FRCP(C)
Kevin Wolfe, MD, FRCP(C)
University of Manitoba; Winnipeg, Manitoba R3A 1R9, Canada
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
