Transesophageal echocardiography and unexplained cerebral ischemia: a multicenter follow-up study. The STEPS Investigators. Significance of Transesophageal Echocardiography in the Prevention of Recurrent Stroke.

BACKGROUND

Transesophageal echocardiography (TEE) continues to play a prominent role in the evaluation of patients with unexplained cerebral ischemia. The STEPS Study Group (Significance of Transesophageal Echocardiography in the Prevention of Recurrent Stroke) was established to further examine the clinical significance of TEE findings in patients with suspected cardiac source of embolus and to assess the impact of these findings with respect to specific therapy and the prevention of recurrent events.

METHODS

A total of 242 patients from 15 institutions within the United States underwent TEE study for evaluation of unexplained cerebral ischemia. Over a 1-year period, detailed follow-up was obtained with respect to recurrent stroke, transient ischemia attacks, or documented embolic events as well as detailed information concerning nonrandomized antithrombotic therapy.

RESULTS

Recurrent stroke occurred in 17 of 132 (13%) of the patients in the aspirin group versus 5 of 110 (5%) of the patients receiving warfarin therapy (P <.02). This decrease in cerebral ischemic events in the warfarin group was noted, despite the higher prevalence of atrial fibrillation and impaired ventricular function in the warfarin group. The selection of antithrombotic therapy appears, at least in part, to have been influenced by the TEE findings. Among patients receiving aspirin, a higher recurrent stroke rate was noted in those with left ventricular enlargement and atherosclerotic aortic plaque.

CONCLUSION

Abnormalities are commonly found by TEE in patients with unexplained cerebral ischemia. Patients with left ventricular enlargement and demonstrable aortic plaque on TEE study are at increased risk for recurrent stroke when receiving aspirin therapy alone. Empiric therapy with systemic anticoagulation may be indicated in patients with stroke unexplained by carotid atherosclerotic disease.