Cardiac Point-of-Care Ultrasound Performed in a Stroke Unit Is Associated with a Reduced Hospital Length of Stay

1. Introduction

Cardioembolic stroke is the etiological subtype associated with the highest burden of disability and accounts for up to 30% of all ischemic strokes [1,2]. Its diagnostic evaluation relies on systematic screening for embolic cardiac sources, in which transthoracic echocardiography (TTE) plays a central role [3]. However, TTE often requires cardiology involvement, which may delay etiological assessment during acute stroke care and prolong in-hospital workflows, potentially impacting hospital length of stay [4].

Cardiac point-of-care ultrasound (cPOCUS) is a focused cardiac ultrasound examination performed by non-cardiologist physicians to address specific clinical questions. Unlike the comprehensive and regulated approach of TTE, cPOCUS is problem-oriented and based on targeted two-dimensional and color Doppler imaging. While standard echocardiography includes transthoracic, transesophageal, and contrast-enhanced modalities, cPOCUS is performed exclusively via the transthoracic approach and is intended to provide a rapid, suggestive assessment rather than a definitive diagnosis [2,4].

In the neurological setting, cPOCUS can be used to screen for embolic cardiac diseases and may be performed by neurologists following structured training. This technique enables the early identification of relevant structural and functional cardiac abnormalities and has the potential to accelerate etiological classification and subsequent management decisions, without increasing the burden on other departments [2,4]. Although cPOCUS protocols vary across organizations, there is general consensus regarding their core components [5,6,7,8,9,10]. Standard protocols typically include parasternal, apical, subcostal, and supraclavicular views using a sector transducer [6,11].

In recent years, neurologist-performed cPOCUS has been increasingly implemented in Stroke Units, where it may expedite cardiac workup and favorably impact length of stay by enabling earlier etiological assessment and clinical decision-making. In this study, we assessed the effect of implementing neurologist-performed cPOCUS on length of stay among patients admitted to a Stroke Unit (SU).

2. Methods

2.1. Study Design and Population

We conducted a retrospective observational study including consecutive patients admitted with a diagnosis of acute ischemic stroke (AIS) between January 2020 and December 2021 to the Stroke Unit of Torrecárdenas University Hospital, Almería, Spain, a tertiary care center serving a reference population of approximately 760,000 inhabitants. Patients were eligible if they required cardiac ultrasonographic evaluation as part of the etiological work-up of cerebrovascular disease.

2.2. Cardiac Imaging Strategy and Study Groups

In patients with ischemic stroke requiring screening for embolic cardiac sources, TTE was requested from the Cardiology Department according to standard clinical practice. In parallel, all patients underwent a scheduled neurosonological evaluation performed by the Neurology Department; on one predefined day per week, the examination was conducted by a neurologist trained in cardiac point-of-care ultrasound (cPOCUS). Consequently, patients admitted or evaluated during these sessions underwent initial cardiac screening with cPOCUS, whereas patients assessed on other days followed the conventional diagnostic pathway with TTE alone.

If cPOCUS revealed no relevant cardiac abnormalities, no further echocardiographic studies were performed. In cases with equivocal findings—such as suspected ventricular dysfunction, valvular abnormalities, or intracardiac masses—and in all patients who did not undergo cPOCUS, TTE was subsequently performed. When TTE was performed as the initial examination, cPOCUS was not carried out.

Patients were classified into two groups: (1) the cPOCUS group, comprising patients who underwent neurologist-performed cPOCUS screening, regardless of whether a TTE was also performed; and (2) the control group, comprising patients who underwent TTE exclusively.

2.3. Variables and Data Collection

Demographic variables included age and sex. Clinical variables comprised vascular risk factors, toxic habits, comorbidities, and stroke-related characteristics. Vascular risk factors included hypertension, dyslipidemia, and diabetes mellitus, defined by prior diagnosis and/or ongoing treatment. Toxic habits included smoking, alcohol use, and illicit drug use. Comorbidities included ischemic heart disease, prior stroke, and atrial fibrillation (pre-existing or newly diagnosed). Stroke characteristics included vascular territory (anterior vs posterior circulation), stroke severity assessed using the National Institutes of Health Stroke Scale (NIHSS), reperfusion therapies (intravenous thrombolysis and/or mechanical thrombectomy), in-hospital complications (lower respiratory tract infection and/or urinary tract infection), and hospital length of stay.

Echocardiographic variables assessed by TTE included left ventricular ejection fraction, left ventricular hypertrophy and dilation, left atrial dilation, segmental wall motion abnormalities, intracardiac masses, and valvular disease. cPOCUS variables included left ventricular hypertrophy and dilation, left atrial dilation, global or segmental hypokinesia, intracardiac masses, and valvular abnormalities.

2.4. cPOCUS Protocol

cPOCUS examinations were performed using a portable ultrasound device (Vivid IQ Premium v204) equipped with a multifrequency sector probe (1.5–4.6 MHz). Standard transthoracic views were obtained following focused cardiac ultrasound principles. All examinations were performed by neurologists specialized in stroke who had received structured training in cPOCUS (AA-P and LA-M).

Cardiac structure and function were assessed qualitatively. Left atrial diameter was measured in the parasternal long-axis view. Left ventricular systolic function was evaluated visually across multiple views and classified as normal, probably reduced, or severely reduced. Segmental wall motion abnormalities were assessed, and intracardiac masses were suspected based on morphology and mobility. Valvular morphology and function were evaluated using two-dimensional and color Doppler imaging.

2.5. Statistical Analysis

Categorical variables were compared using the χ² test or Fisher exact test, as appropriate. Continuous variables were compared using Student’s t test or the Mann–Whitney U test, depending on data distribution.

Multivariable linear regression analysis was performed to identify factors independently associated with hospital length of stay. The model included age, sex, variables previously associated with length of stay (including posterior circulation stroke and infectious complications), and variables with p < 0.20 in univariable analyses. A two-sided p value ≤ 0.05 was considered statistically significant.

Statistical analyses were performed using IBM SPSS Statistics version 27. Figures were generated using Python 3.11, with pandas for data handling and Matplotlib for visualization.

2.6. Ethical Approval

The study was approved by the Provincial Research Ethics Committee of Almería (approval code 102/2022). Informed consent was waived due to the retrospective design and anonymization of data.

3. Results

A total of 808 patients with AIS were admitted to the SU during the study period (Figure 1). Cardiac imaging with cPOCUS and/or TTE was performed during hospitalization in 332 patients (39.4%). Of these, 201 (60.4%) were men, the mean age was 68.4 years (SD 13.3), and the median NIHSS score at admission was 5 (9) (Table 1).

Among the 332 patients who underwent cardiac imaging, 219 (65.9%) were assigned to the cPOCUS group and 113 (34.0%) to the control group. Baseline demographic and clinical characteristics were largely comparable between the cPOCUS and control groups (Table 1). Median age was similar in both groups (70 years in each; p = 0.05), as was sex distribution, with no significant differences in the proportion of women. The prevalence of major vascular risk factors, including hypertension, diabetes mellitus, atrial fibrillation, smoking, alcohol consumption, and drug use, did not differ significantly between groups. Dyslipidemia was more frequent in the cPOCUS group compared with the control group (46.6% vs. 32.7%; p = 0.02). NIHSS score was comparable between groups, as was vascular territory involvement. Regarding acute treatments, the proportion of patients receiving intravenous fibrinolysis did not differ significantly, whereas mechanical thrombectomy was more frequently performed in the cPOCUS group than in the control group (24.7% vs. 14.2%; p = 0.02). Rates of in-hospital complications, including lower respiratory tract infection and urinary tract infection, were similar between groups

Length of stay was significantly longer in the control group compared with the cPOCUS group [8 days (IQR 5) vs. 7 days (IQR 4); p = 0.015] (Figure 2).

Echocardiographic findings among patients with available reports (n = 318) are summarized in Table 2. In the cPOCUS group (n = 207), the most frequent abnormalities were left ventricular hypertrophy (45.0%) and left atrial dilation (28.5%), followed by valvular regurgitation, including aortic insufficiency in 22.2% and mitral insufficiency in 20.2% of patients. Segmental wall motion abnormalities were observed in 14.0%, and intracavitary masses were infrequent (1.9%), with left atrial masses identified in 0.5% of cases. Mitral and aortic stenosis were detected in 6.8% and 6.3% of patients, respectively. In the control group (n = 111), left ventricular hypertrophy was also the most common finding (45.9%), followed by left atrial dilation (38.7%). Valvular insufficiency was present in 23.4% for the mitral valve and 17.1% for the aortic valve, whereas mitral and aortic stenosis were observed in 2.7% and 6.3% of patients, respectively. Segmental wall motion abnormalities were identified in 12.6% of patients, and intracavitary masses were detected in 1.8%, with no left atrial masses reported. Left ventricular systolic function was preserved in most control patients, with a normal ejection fraction in 91.0%, mild reduction in 6.3%, and severe reduction in 2.7%

In multivariable linear regression analysis, evaluation with cPOCUS was independently associated with a shorter hospital length of stay [β coefficient (standard error): −1.49 (0.73)], after adjustment for potential confounding factors (Table 3).

4. Discussion

To our knowledge, this is the first study specifically designed to evaluate the association between neurologist-performed cPOCUS and hospital length of stay in an acute ischemic stroke population. The neurologist-performed cPOCUS was associated with a shorter length of stay among patients admitted to a SU, particularly in a setting with restricted access to non-urgent cardiac imaging techniques.

Echocardiography is a key component of etiological evaluation in ischemic stroke and has been associated with a lower likelihood of undetermined etiology and reduced in-hospital mortality [3]; however, access to this complementary test is frequently limited, which may delay diagnostic completion and subsequent therapeutic decision-making [12]. In this context, the use of focused cardiac ultrasound performed by non-cardiologists with appropriate training has been proposed as a strategy to optimize in-hospital workflows [2].

The clinical utility of cPOCUS performed by non-cardiologists has been evaluated in several studies, in critically ill populations [13,14,15,16]. These studies have shown that cPOCUS is a feasible technique and an effective screening tool for ventricular function, with no relevant differences compared with formal transthoracic echocardiography (TTE) [15], thereby facilitating early management and clinical decision-making [16]. However, the objectives of cPOCUS in these settings differ from those in cerebrovascular disease, where the primary focus is the identification of potential embolic cardiac sources rather than comprehensive cardiac assessment.

In Spain, neurologist-performed cPOCUS has been implemented in a regulated manner since 2019 following accreditation by the Spanish Society of Cardiology [5]. Although its adoption has increased in SU, dissemination remains limited and evidence regarding its overall clinical impact is still scarce (2). Nevertheless, available studies report favorable results. Early experience with simplified echocardiographic protocols, such as the Stroke Echoscan, demonstrated accurate screening for major embolic sources by trained neurologists [4], and subsequent observational studies have confirmed the diagnostic utility of cPOCUS in routine stroke care [2,17]. In a prospective study, López-Dequidt et al. [18] reported improved detection of previously unrecognized structural heart disease, with potential implications for secondary prevention in patients at high risk of early recurrence.

The impact of cPOCUS on hospital length of stay has not been previously examined as a primary outcome in stroke populations. In the present study, implementation of neurologist-performed cPOCUS was associated with a median reduction of one hospital day. Although modest, this difference may be clinically meaningful, as shorter hospitalization has been associated with a lower risk of in-hospital complications and improved efficiency of stroke unit care [1]. In addition, previous studies using focused echocardiographic protocols in acute stroke settings have suggested that earlier etiological assessment may facilitate earlier discharge and more efficient resource utilization [4], potentially translating into reduced healthcare costs.

This study has several limitations. Its retrospective observational design may be associated with information bias. In addition, during the study period, the availability of cPOCUS depended on the presence of an accredited neurosonologist, resulting in a non-random allocation of patients and limiting causal inference. Prospective, multicenter studies with standardized implementation of cPOCUS are warranted to confirm these findings and better define its impact on clinical outcomes and healthcare resource utilization.

5. Conclusions

Our findings should be interpreted in the context of the observational design; nonetheless, they suggest a potential role for cPOCUS as an adjunctive tool to optimize stroke unit workflows.