This article documents the ability of transesophageal echocardiography to provide adequate images and clinically relevant information about the coronary anatomy of the elderly patient. Transesophageal echocardiography is commonly used to assess elderly patients who suffer cerebral vascular accidents. It is important to evaluate not only for the usually suspected causes of a cardiac source of emboli but also for direct and indirect evidence of coronary artery disease - the leading cause of death in the elderly stroke patient. Because atherosclerotic cardiovascular diseases identified in one vascular bed are prone to universally involve the other vascular territories to some degree, it is not surprising that the coronary arteries are often stenotic. As a sudden event with catastrophic symptoms, a stroke is commonly the first vascular event the elderly patient experiences. Depending on the degree of recovery, physical limitations may contribute to the lack of symptoms from coexistent peripheral or coronary artery disease. Transesophageal echocardiography may be the first, or only, coronary evaluation for high-risk elderly patients. © 2001 by Cardiovascular Reviews & Reports, Inc.