focus , focus cardiac ultrasound hhe , handheld echocardiography mi , myocardial infarction te , traditional echocardiography tte , transthoracic echocardiography traditional echocardiography ( te ) is the gold standard for noninvasive assessment of cardiac structure and function . in contrast , hhe can be conceived as a form of point - of - care testing wherein data are gathered , analyzed , and acted on by a provider in a single clinical encounter . nevertheless , many clinicians started applying it in their daily practice and its use has expanded to other developed countries . in a study comparing comprehensive echocardiography between the two modalities , cullen et al . , did find discordant findings in 27% of patients ; however , the most discordant finding was in identification of regional wall abnormalities . in another recent study , hhe was compared with the physical examination in detection of cardiac pathologic characteristics , and hhe was significantly more accurate . importantly , hhe also had a higher negative predictive value , suggesting the prospect of lower downstream costs . a 75-year - old man with diabetes mellitus presented to our emergency department with acute st - elevation myocardial infarction ( mi ) . following thrombectomy and angioplasty , two drug - eluting stents were placed with ensuing thrombolysis in miiii flow across the lesion . the patient was admitted to the intensive care unit under the care of the cardiology service . his cardiac enzyme levels normalized , and repeat electrocardiography showed improving st - segment elevations . transthoracic echocardiography ( tte ) on hospital day 2 showed an ejection fraction of 40% with abnormal wall motion at the mid and apical left ventricular ( lv ) segments [ figure 1 ] . we planned to discharge the patient on hospital day 4 with aspirin , clopidogrel , metoprolol tartrate , lisinopril , and atorvastatin . ejection fraction is 40% with abnormal wall motion at mid and apical left ventricular segments and no evidence of left ventricular thrombus . the cardiology team performed a limited tte with a handheld device ( vscan ge - gm000100 ; general electric co ) . we found an apical lv thrombus , which had not been present 2 days earlier [ figure 2 ] . a formal tte confirmed the thrombus , measuring 1.9  1.5 cm [ figure 3 ] . treatment with heparin and warfarin was started , and the patient was discharged several days later with a therapeutic international normalized ratio . their concern is that physicians will be prone to over diagnosis with resultant unnecessary invasive testing , as well as underdiagnosis with inappropriate ruling out of serious pathologic factors . the task , then , is to study how well hhe can detect specific pathologic conditions through measurement of its specificity and sensitivity . cases such as the present one may help form the parameters of future inquiry . compared with traditional tte , hhe has both device and user limitations . the images have lower resolution and generally doppler imaging is unavailable , though newer generation devices do have doppler capabilities . generally , these devices include m - mode . from a user perspective , most users of hhe are not experts in the acquisition and interpretation of echocardiography . however , the advantages are potentially many . interpretation is made at the time of acquisition , yielding a similar workflow to the classic physical examination . the devices are truly pocket - sized and the technology continues to improve with successive generations . in our experience , hhe has proven useful for both clinical management and teaching . at our institution , medical residents these questions include recognizing grossly impaired lv function , pericardial effusion , and inferior vena cava dilatation . residents are encouraged to practice these skills by routinely carrying the hhe devices during rounds and incorporating hhe into the physical examination , under the supervision of attending cardiologists . the technical training is similar in scope to the focus cardiac ultrasound ( focus ) , articulated by the european association of cardiovascular imaging . however , our experience with the hhe device is that use might be safely and effectively expanded beyond emergency and critical situations , the use case for the focus training . in the present case , we report how hhe meaningfully changed the treatment of this patient who presented with an st - segment elevation mi and how hhe ultimately improved his prognosis . recent guidelines give a tepid grade 2c recommendation for empirical treatment with warfarin and dual antiplatelet therapy for patients with anterior mi status post drug - eluting stent placement and an ejection fraction less than 40% . yet furthermore , addition of warfarin is thought to reduce stroke by only seven events in 1,000 patients . however , if an lv thrombus is positively diagnosed , then 44 fewer strokes would occur among 1,000 patients . without this surprising finding at the bedside , we would not have subjected the patient to the higher bleeding risk associated with anticoagulation . based on this case , a novel clinical application of hhe may be post - mi surveillance for well - known complications . future studies are necessary on the sensitivity and specificity of hhe for specific pathologic conditions . however , this case demonstrates the potential practice - changing power of what has been deemed by some experts to be the stethoscope of the future .
handheld echocardiography ( hhe ) is an emerging technology with potential to alter routine clinical practice . 
 our institution has adopted the use of hhe devices for both teaching and patient care . 
 however , the appropriate clinical scope of hhe continues to be controversial , and the literature is largely devoid of prognosis - altering applications . 
 we report the diagnosis of left ventricular ( lv ) thrombus with hhe . a 75-year - old man presented with a large anteroapical st - elevation myocardial infarction ( mi ) . 
 initial transthoracic echocardiography ( tte ) after percutaneous intervention showed no lv thrombus . before his hospital discharge 
 , hhe was performed and showed lv thrombus . 
 the finding substantially changed the patient 's treatment and prognosis ; he was discharged with warfarin . 
 this observation will help guide further inquiry into the proper clinical role of hhe .