Cardiac emboli account for approximately 15-30% of embolic strokes. TTE can identify some high risk cardiac sources of embolism [e.g. left ventricular (LV) thrombus]. However, the current Canadian Choosing Wisely Guidelines advise against routine use of TTE in the initial work up of IS/TIA patients. Nevertheless, TTEs are commonly ordered for the initial inpatient workup of patients with IS/TIA.

Of the 338 patients admitted for IS/TIA, 278 (82%) received TTE as an inpatient. Of those who received TTE, 11 (4%) had potential clinically actionable findings; LV thrombus (1.4%), ASA (0.36%), PFO (1.8%.), and valvular vegetation (0.36%). Only 2.2% of TTE findings led to change in medical management, 4 started anticoagulation, 1 led to consultation of a medical subspecialty, and 1 led to doppler ultrasound of lower limbs to rule out DVT. None of the patients with a PFO underwent closure or had change in their medical management.

Ordering TTE for the initial work up of IS/TIA remains common practice despite current guidelines. The yield of TTEs are low, and the proportion that lead to changes in medical management is minimal.  The most common abnormality found was PFO, none of which resulted in change in management.