Evaluation of patients with suspected cardiac sources of emboli

The presentation of a patient with an acute arterial embolic event is not only dramatic for the acuity and severity of symptoms; it is also the harbinger of potentially life-threatening disease. Recognition of the many clinical manifestations that can result as emboli travel through the arterial system is the first step in the evaluation for cardiac sources of emboli. While nearly every organ in the body is a potential embolic target, the incidence of clinically apparent embolic events is approximately three times higher in the cerebral circulation than the peripheral circulation. The most common source of cardiac emboli is a left atrial thrombus due to atrial fibrillation, whereas the second most common source is a left ventricular thrombus following an acute myocardial infarction. Other etiologies include endocarditis, cardiac tumors, and aortic atherosclerosis. While a transthoracic echocardiogram (TTE) is the initial imaging test for most patients, transesophageal echocardiography (TTE) has been shown to be superior to TTE at detecting cardiac sources of emboli and is also more cost effective. Once a cardiac source of emboli is identified, management depends on the underlying etiology and patient comorbidities.