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Structural Cardiac Disease causing Stroke


Learning objectives

  • Appropriate settings to look for Cardiac structural defects
  • Supporting evidence to ensure firm diagnosis
  • Treatment options

Introduction

Various Cardiac structural defects can lead to the formation of intracardiac thrombi and cardioembolism. If suspected the first investigations include a clinical history and a search for any determinants that will give a clue. Cardiac symptoms suggestive of ischaemic heart disease, chest pain, breathlessness and palpitations which could suggest an ischaemic cardiomyopathy. A history of rheumatic fever could suggest valvular disease. A history of excess alcohol might suggest an alcoholic cardiomyopathy (or atrial fibrillation). Cardiomyopathy may also be seen with HIV infection. Examination may reveal heart failure, rashes, AF, sighs of chronic liver disease, nicotine staining, hypertension and murmurs. An ECG, CXR and then Echo will be useful. A troponin may be useful acutely if recent myocardial infarction is suspected. Temperature and stigmata for endocarditis must always be considered. Most embolism is thrombotic but other rare sources of emboli are air, fat, cholesterol, bacteria, tumour cells, and particulate matter from injected drugs should be considered in rare cases.

CauseDetails
Impaired LV functionImpaired LV function can be a risk factor for embolism
Infective endocarditisEndocarditis
Marantic endocarditis Cancer and stroke
Atrial myxomaA cause of fever, raised ESR and cardioembolic stroke
MyocarditisOften viral infection with malaise, heart failure, arrhythmias
LV aneurysmUsually seen following Large anterior STEMI. May be LBBB or persisting ST elevation on ECG
CardiomyopathyDiseases affecting heart muscle.
Mitral Valve ProlapseStudies have shown that mitral valve prolapse (MVP) is associated with fibrinous deposits on the valve, endothelial denudation and annular thrombus at the junction with the atrial wall. The myxomatous redundant valve leaflets appear to increase the predisposition to thromboembolic events. There is no evidence for antithrombotic treatment other than antiplatelets in those who have experienced stroke. There should be a search for undetected PAF.
Mitral annulus calcificationIs seen with mitral stenosis, mitral regurgitation and may be increased in those with cardiogenic brain embolism. Detected on echocardiography it suggests a twofold increase in risk for stroke. Embolism of fibrinated cell clot or calcium spicules has been reported.
Patent foramen ovale + DVTPatent Foramen Ovale
Prosthetic Heart ValvesDiseased and damaged heart valves are often replaced with either mechanical or bioprosthetic (tissue) valves. Tissue prosthetic valves are believed to be associated with a smaller risk of thromboembolism than mechanical valves. Mitral valve prostheses are associated with a greater risk of thromboembolism than Aortic, possibly because of the higher incidence of atrial fibrillation and other thromboembolic risk factors in these patients.

Investigations

  • FBC, ESR, CRP: raised ESR or CRP may suggest atrial myxoma or malignancy
  • ECG: AF, ST elevation suggests STEMI or Aneurysmal LV
  • CXR: Cardiomegaly
  • Transthoracic Echo: assesses LA size, LV and function and valves
  • Transoesophageal Echo: assesses LA size, LV and function and valves
  • Cardiac MRI: useful for some cardiomyopathies

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