CARDIAC EVALUATION OF STROKE PATIENTS

There are two potential purposes for cardiac evaluation in patients wi th cerebrovascular disease: to identify possible cardioembolic pathoph ysiology for ischemic symptoms and to identify concomitant coronary ar tery disease. Both have important implications for patient prognosis a nd treatment, and testing therefore appears to be warranted. On the ot her hand, the cost conservation movement in medicine dictates that phy sicians limit unnecessary, costly, possibly risky testing when the dia gnostic yield is low. For example, the overall yield of cardiac testin g in ''usual stroke patients'' who have no suggestive history or findi ngs on examination, chest X-ray, or electrocardiogram is less than 10% and may not be indicated routinely. Conversely, young patients with s troke of unknown cause are likely to benefit from aggressive cardiac t esting. Many reported series and clinical trials have demonstrated tha t patients with cerebrovascular disease are more likely to die in foll ow-up from cardiovascular than from cerebrovascular causes. This risk is best defined and may be highest in patients with carotid disease, i n whom the 5-year cardiac mortality rate may be as high as 40 to 50%. Studies have shown that such patients are also Likely to have abnormal tests for cardiac ischemia, even when a history of cardiovascular eve nts or symptoms or electrocardiographic abnormalities are lacking. The se results, combined with further investigations into which cerebrovas cular patients are at highest risk for cardiovascular disease and what testing best identifies underlying, treatable cardiovascular disease, are needed to direct the care and improve the cardiovascular prognosi s of patients with cerebrovascular disease.