To elucidate the clinical utility in performing TTE in all patients that present for first-time stroke.

Transthoracic echocardiogram (TTE) is a “moderate” recommendation under the 2021 AHA/ASA Guidelines. We aimed to identify in which patients TTE is most likely to reveal a clinically relevant finding that helps guide workup and secondary stroke prevention.

We reviewed records of patients at an academic stroke center with a primary discharge diagnosis of ischemic stroke between January 1-December 31, 2019 excluding those with prior stroke(s). Stroke location was classified as cortical, subcortical, brainstem, multiple/multifocal. TTE findings that were defined as clinically significant included reduced ejection fraction, enlarged left atrial size, patent foramen ovale, vegetations, thrombus, and atrial fibrillation during the procedure. Chi-square and Fisher’s exact association tests were used for two-way tables, relative risk, and logistic regressions.

Of the 307 identified patients admitted for first time stroke, 181 (59.0%) were male, and median age was 63.6+/-14.3 years. Stroke location was cortical in 99 (32.2%), subcortical in 41(13.4%), brainstem in 39 (12.7%), and multiple/multifocal in 128 (41.7%). Clinically significant findings on TTE were found in 150 patients (48.9%). Age predicted clinically significant TTE (risk ratio per 10-year interval 1.11, 95% CI 1.02-1.20). Atrial fibrillation and cortical location predicted clinically significant TTE findings. Other locations and risk factors were not associated with clinically significant TTE.

Cortical stroke was the only location associated with clinically significant TTE findings. The lack of association with multifocal strokes was surprising as they are often presumed cardioembolic. This suggests that TTE may be most beneficial in evaluating cortical stroke, but given that nearly half of all stroke patients had TTE findings that would inform further management suggests that continuing universal TTEs is beneficial.