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neuro.stroke-cardioembolic.v1

Cardioembolic Stroke (TOAST CE)

neurologyacutechronicadultacuteinpatientoutpatient
Start encounter →Print handoutPRODUCTION

Phase C wave-14 shard-3 neuro stroke-phenotype expansion (2026-05-15): authored at INTEGRATED tier — manifest forward-declared. 10 phenotype severity_triggers span the CE TOAST class: AF-associated / LV thrombus post-MI / valvular (mech + bioprosthetic) / mural thrombus ICM / cardiac tumor / IE septic emboli / paradoxical PFO / LV aneurysm / bioprosthetic <3 mo / Watchman LAA closure. 5 setting playbooks span the full CE journey: ed (acute confirmation + reversal-readiness) → icu (post-reperfusion + hemorrhagic-conversion + IE complications) → inpatient (1-3-6-12 day rule DOAC timing + PFO / LV thrombus / valve / IE branching) → outpatient (90-d / 12-mo + anticoag adherence + AF surveillance + LAA closure surveillance) → home (anticoag adherence + bleed awareness + AF symptom recognition). Schema-blocked downstream (depth bundle): calc.ros_pfo (RoPE score), calc.endocarditis_embolic_risk, calc.laa_closure_eligibility (Watchman criteria). Surfaced in depth bundle until clinical-tools-registry expands. Regimen axis with 7 steps: AF DOAC per 1-3-6-12 day rule → mechanical valve warfarin → LV thrombus warfarin 3-6 mo → PFO closure post-procedure regimen → IE deferred anticoag → Watchman LAA closure regimen → BP/LDL/glycemic/smoking secondary prevention bundle. Sibling differentiation: neuro.ischaemic-stroke.v1 (parent acute; reperfusion lives there), cardio.afib.core.v1 (AF long-term mgmt), cardio.infective-endocarditis.core.v1 (IE acute), neuro.tia.v1 (TIA-spectrum CE). All siblings are pre-existing registered engines.

Entry points (7)

  • symptom
    Cortical / multi-territory embolic-pattern infarct on MRI DWI suggesting CE mechanism (AHA/ASA 2021 PMID 34024117)
    cortical_embolic_infarct_pattern
  • history
    Known atrial fibrillation — most common CE source (2024 ESC AF)
    known_atrial_fibrillation
  • history
    Mechanical or bioprosthetic valve — warfarin-mandatory CE source (2020 ACC/AHA VHD)
    mechanical_or_bioprosthetic_valve
  • imaging
    LV thrombus on TTE/CMR post-MI (AHA/ASA 2021)
    lv_thrombus_post_mi
  • imaging
    Atrial myxoma or cardiac tumor on TTE/TEE (rare CE source)
    cardiac_tumor_or_atrial_myxoma
  • history
    Infective endocarditis — septic emboli (AHA Endocarditis 2015; AHA/ASA 2021)
    recent_endocarditis
  • imaging
    PFO with high-risk anatomy (atrial septal aneurysm, large shunt) in cryptogenic stroke ≤60 yo (CLOSE/RESPECT/REDUCE)
    pfo_with_high_risk_anatomy

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    Age affects DOAC dose (apixaban renal-criteria), PFO closure eligibility (≤60 yo per CLOSE/RESPECT), and bleed risk
  • nihssrequired
    symptom • used at TREATMENT
    NIHSS gates DOAC start timing per 1-3-6-12 day rule: NIHSS <8 day 3, NIHSS 8-15 day 6, NIHSS ≥16 day 12 (2024 ESC AF)
  • mri_brain_dwirequired
    imaging • used at INITIAL_WORKUP
    Confirms ischemic territory + cortical / multi-territory embolic pattern supporting CE mechanism (AHA/ASA 2021)
  • ecg_telemetry_continuousrequired
    imaging • used at INITIAL_WORKUP
    ECG + continuous telemetry ≥24 h for AF detection (AHA/ASA 2021 Class I); consider 30-day MCT or ILR if cryptogenic (CRYSTAL-AF Sanna NEJM 2014 PMID 24963567)
  • tterequired
    imaging • used at INITIAL_WORKUP
    Transthoracic echo for LV thrombus, valvular disease, wall motion (AHA/ASA 2021 Class I)
  • tee_if_indicated
    imaging • used at BRANCHING_WORKUP
    TEE for PFO, atrial appendage, valvular vegetations, aortic atheroma when TTE non-diagnostic or PFO suspected (AHA/ASA 2021)
  • creatininerequired
    lab • used at TREATMENT
    eGFR for DOAC dosing (apixaban 2.5 mg BID if 2 of: age ≥80, weight ≤60, Cr ≥1.5; rivaroxaban 15 mg if CrCl 15-50; avoid DOAC if CrCl <15)
  • inrrequired
    lab • used at TREATMENT
    INR for warfarin dosing if mechanical valve or DOAC-contraindicated (target 2-3 for most; 2.5-3.5 mechanical mitral)
  • platelet_countrequired
    lab • used at TREATMENT
    Platelets for anticoag bleed risk; cytopenia changes timing decisions
  • troponin
    lab • used at INITIAL_WORKUP
    Troponin for MI-LV-thrombus phenotype detection (post-MI anticoag 3-6 mo for apical akinesis)
  • blood_cultures
    lab • used at BRANCHING_WORKUP
    Blood cultures × 3 if endocarditis suspected (Duke criteria; AHA Endocarditis 2015)
  • recent_mi
    history • used at CONTEXT
    Recent MI with apical akinesis → LV thrombus risk → warfarin 3-6 mo (AHA/ASA 2021)
  • mechanical_valve_historyrequired
    history • used at TREATMENT
    Mechanical valve mandates warfarin (DOAC contraindicated; RE-ALIGN halted); target INR 2.5-3.5 mitral, 2-3 aortic (2020 ACC/AHA VHD)
  • prior_anticoagulation_failure
    history • used at CONTEXT
    Stroke on therapeutic anticoag → reassess: subtherapeutic INR (warfarin), missed DOAC doses, additional mechanism, or LAA closure consideration (2024 ESC AF)
  • current_anticoagulantrequired
    medication • used at CONTEXT
    Existing anticoag on board + last dose drives bridging decisions and reversal needs

12-phase flow (12)

  1. 1FRAME
    Ischemic stroke with cardioembolic mechanism — AF, LV thrombus, valvular, mural thrombus, cardiac tumor, endocarditis, PFO, LV aneurysm, bioprosthetic <3 mo (AHA/ASA 2021; 2024 ESC AF)
    advance: CE mechanism flagged or being investigated
  2. 2ENTRY
    Receives patient from neuro.ischaemic-stroke.v1 with CE suspicion based on embolic infarct pattern + AF / valvular / thrombus history
    inputs: known_atrial_fibrillation
    advance: CE pathway activated
  3. 3CONTEXT
    Capture AF / valvular / MI / recent endocarditis / prior anticoag history / renal function / current meds (AHA/ASA 2021)
    inputs: age, current_anticoagulant, creatinine, mechanical_valve_history, recent_mi
    advance: Cardiac context captured
  4. 4RED_FLAGS
    Septic embolic stroke from active endocarditis (route to cardio.infective-endocarditis.core.v1 for surgery decision); mechanical valve stroke (urgent warfarin restart); hemorrhagic conversion on anticoag (reversal + neurosurgery)
    inputs: blood_cultures
    advance: Critical phenotypes addressed
  5. 5INITIAL_WORKUP
    TTE + continuous telemetry ≥24 h + MRI DWI + lipid panel + renal + coag (AHA/ASA 2021 Class I)
    inputs: mri_brain_dwi, ecg_telemetry_continuous, tte
    actions: panel.renal, panel.cbc, panel.coag
    advance: Initial cardiac + neuro workup complete
  6. 6BRANCHING_WORKUP
    TEE if PFO / appendage / vegetations suspected; 30-day MCT or ILR if cryptogenic with embolic-pattern infarct (CRYSTAL-AF Sanna NEJM 2014 PMID 24963567); cardiac MRI for LV thrombus when TTE non-diagnostic
    inputs: tee_if_indicated
    advance: CE source localised — AF / LV thrombus / valvular / endocarditis / PFO / cardiac tumor / cryptogenic-with-extended-monitoring
  7. 7DIFFERENTIAL
    CE sub-phenotype: AF-associated / LV thrombus post-MI / mechanical valve / bioprosthetic ≤3 mo / native valve / endocarditis / paradoxical PFO / LV aneurysm / cardiac tumor / cryptogenic with strong CE signal (AHA/ASA 2021; 2024 ESC AF)
    advance: CE sub-phenotype assigned
  8. 8RISK_STRATIFICATION
    NIHSS times DOAC start; CHA2DS2-VASc (auto-≥2 with stroke for AF, anticoag mandatory); HAS-BLED for modifiable bleed factors (2024 ESC AF)
    inputs: nihss
    advance: NIHSS + CHA2DS2-VASc + HAS-BLED documented
  9. 9TREATMENT
    Anticoagulation per phenotype: AF → DOAC (apixaban first-line ARISTOTLE PMID 21870978; timing 1-3-6-12 d by NIHSS per 2024 ESC AF); mechanical valve → warfarin INR 2.5-3.5 mitral / 2-3 aortic (RE-ALIGN halted DOAC); LV thrombus → warfarin 3-6 mo; PFO ≤60 + high-risk anatomy → percutaneous closure (CLOSE Mas NEJM 2017 PMID 28902533); LAA closure if anticoag contraindicated (PROTECT-AF/PREVAIL); endocarditis → defer anticoag until 2-4 wk post-event + valve surgery decision (AHA Endocarditis 2015)
    inputs: nihss, creatinine, inr, mechanical_valve_history
    advance: Anticoagulation strategy executed or excluded with rationale
  10. 10DISPOSITION
    Inpatient continuation of acute stroke care + cardiology consult; outpatient stroke clinic + cardiology / EP / structural follow-up (AHA/ASA 2021)
    advance: Disposition documented
  11. 11MONITORING
    Continuous telemetry inpatient; outpatient MCT or ILR if cryptogenic; INR / DOAC renal monitoring; HAS-BLED reassessment; LAA closure surveillance if performed (AHA/ASA 2021; 2024 ESC AF)
    advance: Monitoring plan documented
  12. 12FOLLOWUP
    Stroke clinic 7-14 d + 90 d + 12 mo: BP <130/80, LDL <55, HbA1c <7%, smoking cessation, anticoag adherence + HAS-BLED, AF surveillance, valve surveillance (AHA/ASA 2021)
    actions: panel.lipid
    advance: Secondary prevention bundle on board + cardiology follow-up scheduled