Cardioembolic sources and stroke prevention: a systematic review

Cardioembolism is one of the most frequent and clinically severe mechanisms underlying ischemic stroke, accounting for a substantial proportion of global morbidity and mortality. Despite declining age-adjusted mortality rates in high-income countries, the absolute number of strokes continues to increase, largely driven by population ageing and the rising prevalence of cardiovascular comorbidities. Timely identification of cardiac sources of embolism is therefore essential to optimize secondary prevention and improve long-term neurological outcomes. The range of potential cardiac substrates is wide and includes atrial fibrillation, native and prosthetic valvular disease, left ventricular thrombus, aortic arch atheroma, intracardiac masses, and right-to-left shunts such as patent foramen ovale. Echocardiography represents the cornerstone of the diagnostic work-up in patients with suspected cardioembolic events. Transthoracic echocardiography provides rapid, non-invasive evaluation of cardiac morphology and global function, while transesophageal echocardiography offers superior visualization of high-risk structures, particularly the left atrial appendage, prosthetic valves, and the thoracic aorta. Advances in three-dimensional imaging and Doppler technology have further improved the ability to delineate complex anatomy and hemodynamic abnormalities with high accuracy. Although additional imaging modalities such as cardiac computed tomography and cardiac magnetic resonance may offer complementary anatomical or tissue-characterization data in selected cases, their use should be individualized and reserved for scenarios in which echocardiographic assessment is insufficient to fully characterize a suspected embolic source. Cardioembolic stroke continues to represent a major clinical and socioeconomic burden worldwide. While progress in cardiac imaging has substantially improved the detection and characterization of embolic substrates, diagnostic strategies must extend beyond imaging alone. A truly effective and cost-efficient work-up requires integration of clinical information—including patient age, cardiovascular risk profile, predisposing infectious conditions, and overall clinical presentation—to guide appropriate use of diagnostic resources. Incorporating these variables enables more personalized selection of imaging modalities, avoids unnecessary tests, accelerates diagnosis, and ultimately supports more targeted preventive strategies. Strengthening this clinically driven, patient-specific approach is essential to reducing the global impact of embolic stroke and improving cerebrovascular outcomes. scenario-based diagnostic approach to cardioembolic stroke, guiding tailored imaging strategies and targeted preventive therapy according to patient clinical profile.