| Reworded | All patients with stroke are recommended undergoing routine chest X-rays and transthoracic echocardiography to search for possible cardiac structural diseases. | I | C |
| Reworded | For patients who had a stroke with suspected embolic aetiology, performing transoesophageal echocardiography to look for left atrial appendage thrombus, patent foramen ovale (PFO) or atrial septal aneurysm is reasonable. | IIa | B |
| Unchanged | Transthoracic echocardiography cannot be replaced by transoesophageal echocardiography. | III | C |
| Reworded | Cardiac MRI is effective in identifying the aetiology of cryptogenic stroke. It is recommended performing when available. | I | A |
| Reworded | Cardiac abnormalities detected during cardiovascular screening in patients who had a stroke should be actively managed under the guidance of a specialist physician. | I | B |
| New recommendation | In patients suspected of having a PFO-related stroke, transcranial Doppler (TCD) with bubbles might be reasonable to screen for the presence of a right-to-left shunt. | I | B |
| TCD compares favourably with transthoracic echocardiography for detecting right-to-left shunting, which is usually the result of PFO, now a potential target for device closure.125 A pooled analysis of the Oxford Vascular Study data with data from two previous smaller studies of bubble TCD in patients ≥50 years of age found an association between right-to-left shunting and cryptogenic TIA or non-disabling stroke (OR 2.35, 95% CI 1.42 to 3.90). A pooled analysis of a systematic literature review found that TCD had a sensitivity of 96.1% (95% CI 93.0% to 97.8%) and specificity of 92.4% (95% CI 85.5% to 96.1%) compared with transthoracic echocardiography (gold standard) for detection of right-to-left shunting.126
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| New recommendation | For patients with IS, it is recommended performing a 12-lead ECG to screen for atrial fibrillation and atrial flutter, and assess for other concurrent cardiac conditions. | I | B |
| The 12-lead ECG is a simple, non-invasive means of diagnosing atrial fibrillation in patients with acute stroke. A meta-analysis found that the proportion of patients diagnosed with post-stroke atrial fibrillation in the emergency department by ECG was 7.7% (95% CI 5.0% to 10.8%). ECG can also detect pertinent comorbidities that may have therapeutic implications. About 3% of patients presenting with acute stroke also have an acute MI. |
| Reworded | It is advisable to conduct routine pulse examinations for patients aged >65 years and perform a 12-lead ECG for those with abnormal findings. | I | A |
| Reworded | For patients with persistent atrial fibrillation, Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or TIA (CHADS2) or Congestive heart failure, Hypertension, Age ≥75, Diabetes mellitus, prior Stroke or TIA, Vascular disease, Age 65–74, sex category (CHA2DS2-VASc) score is recommended to assess for their stroke risk and guide the management. | I | A |
| Reworded | It is reasonable to use outpatient mobile long-term telemetry, implantable loop recorders or other methods for ≥24 hours of long-term cardiac monitoring in patients with potential cryptogenic stroke, for the purpose of detecting any paroxysmal atrial fibrillation or atrial tachycardia. | IIa | B |
| Unchanged | For patients with non-persistent atrial fibrillation or paroxysmal atrial fibrillation/atrial tachycardia (>5.5 hours) within 30 days or paroxysmal atrial fibrillation for >30 s, the stroke prevention therapy is the same as those with chronic or persistent atrial fibrillation. | IIb | B |
| Reworded | Research suggests an association with thromboembolic events for arrhythmias other than atrial fibrillation, atrial flutter and paroxysmal supraventricular tachycardia. However, there is a lack of evidence demonstrating that interventions on these arrhythmias can reduce the occurrence of thromboembolic events. Therefore, it is recommended approaching the treatment based on the individual clinical condition. | III | C |
| Reworded | Reduced blood flow velocity in the left atrium, left atrial appendage and left ventricle, as well as spontaneous echocardiographic contrast in the left atrium, are independent risk factors for thrombus formation and subsequent thromboembolic events. It is necessary to investigate the underlying causes and intervene accordingly. | IIa | B |