1
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Lüscher TF, Davies A, Beer JH, Valgimigli M, Nienaber CA, Camm JA, Baumgartner I, Diener HC, Konstantinides SV. Towards personalized antithrombotic management with drugs and devices across the cardiovascular spectrum. Eur Heart J 2022; 43:940-958. [PMID: 34624084 DOI: 10.1093/eurheartj/ehab642] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 05/06/2021] [Accepted: 09/01/2021] [Indexed: 01/10/2023] Open
Abstract
Intravascular thrombus formation and embolization are among the most frequent events leading to a number of cardiovascular conditions with high morbidity and mortality. The underlying causes are stasis of the circulating blood, genetic and acquired coagulation disorders, and reduced antithrombotic or prothrombotic properties of the vascular wall (Virchow's triad). In the venous system, intravascular thrombi can cause venous thrombosis and pulmonary and even peripheral embolism including ischaemic stroke [through a patent foramen ovale (PFO)]. Thrombi in the left atrium and its appendage or ventricle form in the context of atrial fibrillation and infarction, respectively. Furthermore, thrombi can form on native or prosthetic aortic valves, within the aorta (in particular at sites of ulcers, aortic dissection, and abdominal aneurysms), and in cerebral and peripheral arteries causing stroke and critical limb ischaemia, respectively. Finally, thrombotic occlusion may occur in arteries supplying vital organs such the heart, brain, kidney, and extremities. Thrombus formation and embolization can be managed with anticoagulants and devices depending on where they form and embolize and on patient characteristics. Vitamin K antagonists are preferred in patients with mechanical valves, while novel oral anticoagulants are first choice in most other cardiovascular conditions, in particular venous thromboembolism and atrial fibrillation. As anticoagulants are associated with a risk of bleeding, devices such as occluders of a PFO or the left atrial appendage are preferred in patients with an increased bleeding risk. Platelet inhibitors such as aspirin and/or P2Y12 antagonists are preferred in the secondary prevention of coronary artery disease, stroke, and peripheral artery disease either alone or in combination depending on the clinical condition. A differential and personalized use of anticoagulants, platelet inhibitors, and devices is recommended and reviewed in this article.
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Affiliation(s)
- Thomas F Lüscher
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Allan Davies
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK
| | - Juerg H Beer
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Marco Valgimigli
- CardioCentro, Lugano, Switzerland.,University of Bern, Bern, Switzerland
| | - Christoph A Nienaber
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK
| | - John A Camm
- St. Georges University and Imperial College, London, UK
| | | | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty of the University Duisburg-Essen, Duisburg-Essen, Germany
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Suwa Y, Miyasaka Y, Taniguchi N, Harada S, Nakai E, Shiojima I. Atrial fibrillation and stroke: importance of left atrium as assessed by echocardiography. J Echocardiogr 2022; 20:69-76. [DOI: 10.1007/s12574-021-00561-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/04/2021] [Accepted: 12/10/2021] [Indexed: 10/19/2022]
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3
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Miyauchi S, Tokuyama T, Uotani Y, Miyamoto S, Ikeuchi Y, Okamura S, Okubo Y, Katayama K, Takasaki T, Nakatani N, Matsudaira Y, Furusho H, Miyauchi M, Takahashi S, Nakano Y. Association between Left Atrial Appendage Fibrosis and Thrombus Formation: A Histological Approach. J Cardiovasc Electrophysiol 2022; 33:677-687. [DOI: 10.1111/jce.15384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/29/2021] [Accepted: 12/02/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Shunsuke Miyauchi
- Department of Cardiovascular MedicineGraduate School of Biomedical and Health SciencesHiroshima University1‐2‐3, Kasumi, Minami‐kuHiroshimaJapan
- Health Service CenterHiroshima University1‐7‐1 KagamiyamaHigashihiroshimaJapan
| | - Takehito Tokuyama
- Department of Cardiovascular MedicineGraduate School of Biomedical and Health SciencesHiroshima University1‐2‐3, Kasumi, Minami‐kuHiroshimaJapan
| | - Yukimi Uotani
- Department of Cardiovascular MedicineGraduate School of Biomedical and Health SciencesHiroshima University1‐2‐3, Kasumi, Minami‐kuHiroshimaJapan
| | - Shogo Miyamoto
- Department of Cardiovascular MedicineGraduate School of Biomedical and Health SciencesHiroshima University1‐2‐3, Kasumi, Minami‐kuHiroshimaJapan
| | - Yoshihiro Ikeuchi
- Department of Cardiovascular MedicineGraduate School of Biomedical and Health SciencesHiroshima University1‐2‐3, Kasumi, Minami‐kuHiroshimaJapan
| | - Sho Okamura
- Department of Cardiovascular MedicineGraduate School of Biomedical and Health SciencesHiroshima University1‐2‐3, Kasumi, Minami‐kuHiroshimaJapan
| | - Yousaku Okubo
- Department of Cardiovascular MedicineGraduate School of Biomedical and Health SciencesHiroshima University1‐2‐3, Kasumi, Minami‐kuHiroshimaJapan
| | - Keijiro Katayama
- Department of Cardiovascular SurgeryHiroshima University Hospital1‐2‐3, Kasumi, Minami‐kuHiroshimaJapan
| | - Taiichi Takasaki
- Department of Cardiovascular SurgeryHiroshima University Hospital1‐2‐3, Kasumi, Minami‐kuHiroshimaJapan
| | - Nobuhiro Nakatani
- Medical Division, Technical CenterHiroshima University1‐2‐3, Kasumi, Minami‐kuHiroshimaJapan
| | - Yorisato Matsudaira
- Department of Oral and Maxillofacial Pathobiology, Graduate School of Biomedical and Health SciencesHiroshima University1‐2‐3, Kasumi, Minami‐kuHiroshimaJapan
| | - Hisako Furusho
- Department of Oral and Maxillofacial Pathobiology, Graduate School of Biomedical and Health SciencesHiroshima University1‐2‐3, Kasumi, Minami‐kuHiroshimaJapan
| | - Mutsumi Miyauchi
- Department of Oral and Maxillofacial Pathobiology, Graduate School of Biomedical and Health SciencesHiroshima University1‐2‐3, Kasumi, Minami‐kuHiroshimaJapan
| | - Shinya Takahashi
- Department of Surgery, Graduate School of Biomedical and Health SciencesHiroshima University1‐2‐3, Kasumi, Minami‐kuHiroshimaJapan
| | - Yukiko Nakano
- Department of Cardiovascular MedicineGraduate School of Biomedical and Health SciencesHiroshima University1‐2‐3, Kasumi, Minami‐kuHiroshimaJapan
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Vincenti A, Porcu L, Sonaglioni A, Genovesi S. Proposal for a clinical and an echocardiographic score for prediction of left atrial thrombosis in atrial fibrillation patients undergoing early electrical cardioversion. Int J Clin Pract 2021; 75:e14706. [PMID: 34363727 PMCID: PMC9286836 DOI: 10.1111/ijcp.14706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/05/2021] [Indexed: 11/30/2022] Open
Abstract
AIMS Left atrial thrombosis (LAT) is usually detected by transesophageal echocardiography (TEE). The aim of the present study was to identify clinical and echocardiographic factors associated with left atrial thrombosis in atrial fibrillation (AF) patients undergoing early electrical cardioversion (ECV) in order to create scores that can predict LAT, in a non-invasive way. METHODS A consecutive cohort of patients with persistent AF scheduled for ECV was evaluated by transthoracic echocardiography and TEE. By a logistic regression model, variables significantly associated with LAT were assessed and introduced in predictive models to develop both a clinical and an echocardiographic prediction score for the presence of LAT. RESULTS In total, 125 patients [median 71 (range 49-88) years, 60.0% males] were enrolled. Transesophageal echocardiography showed LAT in 35 patients (28%). The clinical variables significantly associated with LAT were previous stroke (OR = 4.17), higher CHA2 DS2 -VASc score (OR = 1.93), lower estimated glomerular filtration rate (OR = 0.80), and higher brain natriuretic peptide levels (OR = 1.44). Among echocardiographic parameters, E/e' ratio was directly associated with LAT (OR = 2.25), while an inverse correlation was detected with left ventricular ejection fraction (OR = 0.43) and total global left atrial strain (OR = 0.59). Two prediction scores (clinical and echocardiographic) were developed. The positive predictive values of the clinical and the echocardiographic score were 80% and 100%, respectively, while the negative predictive values were 98% and 94%, respectively. Combined use of the scores reached a positive and negative predictive value of 100%. CONCLUSIONS When providing concordant information the two scores are able to correctly identify patients with or without LAT. An external validation is necessary to demonstrate their usefulness in the clinical practice.
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Affiliation(s)
- Antonio Vincenti
- Department of CardiologyOspedale San Giuseppe, MultiMedica IRCCSMilanItaly
| | - Luca Porcu
- Department of OncologyIstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
| | - Andrea Sonaglioni
- Department of CardiologyOspedale San Giuseppe, MultiMedica IRCCSMilanItaly
| | - Simonetta Genovesi
- School of Medicine and SurgeryUniversity of Milano ‐ BicoccaMilanItaly
- Department of Cardiovascular, Neural, and Metabolic SciencesIstituto Auxologico Italiano IRCCSMilanItaly
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Akamatsu K, Ito T, Ozeki M, Miyamura M, Sohmiya K, Hoshiga M. Left atrial spontaneous echo contrast occurring in patients with low CHADS 2 or CHA 2DS 2-VASc scores. Cardiovasc Ultrasound 2020; 18:31. [PMID: 32738924 PMCID: PMC7395968 DOI: 10.1186/s12947-020-00213-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 07/28/2020] [Indexed: 11/10/2022] Open
Abstract
Background Left atrial spontaneous echo contrast (LASEC) is common in patients with atrial fibrillation (AF), although scarce information exists on LASEC occurring in nonvalvular AF patients who have low thromboembolic risk scores. We therefore examined prevalence and determinants of LASEC under low CHADS2 or CHA2DS2-VASc scores in these patients. Methods Among 713 patients who underwent transesophageal echocardiography, 349 with a CHADS2 score < 2 (CHADS2 group) (93 women, mean age 65 years) and 221 with a CHA2DS2-VASc score < 2 (CHA2DS2-VASc group) (39 women, mean age 62 years) were separately examined for clinical and echocardiographic findings. Results LASEC was found in 77 patients of CHADS2 group (22%) and in 41 of CHA2DS2-VASc group (19%). Multivariate logistic regression analysis, adjusted for several parameters including non-paroxysmal AF, LA enlargement (LA diameter ≥ 50 mm), left ventricular (LV) hypertrophy, and an elevated B-type natriuretic peptide (BNP) (BNP ≥200 pg/mL) revealed that for CHADS2 group, non-paroxysmal AF (Odds ratio 5.65, 95%CI 3.08–10.5, P < 0.001), BNP elevation (Odds ratio 3.42, 95%CI 1.29–9.06, P = 0.013), and LV hypertrophy (Odds ratio 2.26, 95%CI 1.19–4.28, P = 0.013) were significant independent determinants of LASEC, and that for CHA2DS2-VASc group, non-paroxysmal AF (Odds ratio 3.38, 95%CI 1.51–7.54, P = 0.003) and LV hypertrophy (Odds ratio 2.53, 95%CI 1.13–5.70, P = 0.025) were significant independent determinants of LASEC. Conclusions LASEC was present in a considerable proportion of patients with nonvalvular AF under low thromboembolic risk scores. Information on AF chronicity, BNP, and LV hypertrophy might help identify patients at risk for thromboembolism, although large-scale studies are necessary to confirm our observations.
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Affiliation(s)
- Kanako Akamatsu
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, 569-8686, Japan
| | - Takahide Ito
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, 569-8686, Japan.
| | - Michishige Ozeki
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, 569-8686, Japan
| | - Masatoshi Miyamura
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, 569-8686, Japan
| | - Koichi Sohmiya
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, 569-8686, Japan
| | - Masaaki Hoshiga
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, 569-8686, Japan
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Biomarkers for Predicting Left Atrial or Left Atrial Appendage Thrombus in Anticoagulated Patients with Nonvalvular Atrial Fibrillation. Cardiol Res Pract 2020; 2020:1683142. [PMID: 32655946 PMCID: PMC7322584 DOI: 10.1155/2020/1683142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 04/26/2020] [Accepted: 05/23/2020] [Indexed: 01/09/2023] Open
Abstract
Purpose Although atrial fibrillation (AF) is often associated with thromboembolic complications, there is no definite biomarker for detecting the presence of thrombi in the left atrial (LA) or left atrial appendage (LAA) in patients with nonvalvular atrial fibrillation (NVAF). Methods NVAF patients who underwent transesophageal echocardiography (TEE) to evaluate LA/LAA thrombus and spontaneous echo contrast (SEC) before AF ablation were included. Multivariate logistic regression and receiver operating characteristic curve (ROC) analyses were performed to explore the independent risk factors of LA/LAA thrombus and indicate the best cutoff point. Results Of the 260 consecutive subjects (mean age: 63.67 ± 9.39 years; 42% women), 45 (17.3%) patients were with LA/LAA thrombus, 131 (50.4%) were with SEC, and 84 (32.3%) were with neither thrombus nor SEC. The results of multivariate logistic regression analysis showed that N-terminal pro-B-type natriuretic peptide (NT-proBNP) (OR, 2.179; 95% CI: 1.191–3.987; p=0.012) and red cell distribution width (RDW) (OR, 2.398; 95% CI: 1.075–5.349; p=0.033) were independently correlated with the presence of LA/LAA thrombus but not D-dimer (OR, 0.999; 95% CI: 0.998–1.000; p=0.210). When all patients were divided into four groups based on the combination between RDW (cutoff value: 12.95%) and NT-proBNP levels (cutoff value: 368.9 ng/L), the rate of LA/LAA thrombus was the highest in the high RDW and NT-proBNP group. Conclusion In anticoagulation patients with NVAF, elevated NT-proBNP and RDW are related to LA/LAA thrombus. Therefore, these might be considered as useful prognostic markers in the management and treatment of NVAF patients.
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7
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Abstract
PURPOSE OF REVIEW Atrial fibrillation is one of the most common clinically encountered arrhythmias exhibiting a strong association with a spectrum of cerebral injuries from the occurrence of clinical stroke, subclinical stroke, dementia, and cognitive decline. Dynamic noninvasive specific and sensitive diagnostic tests may allow a personalized approach to the atrial fibrillation patient's treatment based upon quantitative parameters, aiming to prevent or delay stroke, dementia, progressive cognitive decline, or to assess responses to these therapies. This review will explore molecular markers that have been shown to have an association with atrial fibrillation, and have a potential to be predictive for the risk for stroke, cognitive dysfunction, and dementia in these patients. RECENT FINDINGS Circulating biomarkers of vascular disease, fibrosis, thrombosis, and inflammation are associated with risk of stroke in patients with atrial fibrillation. These biomarkers are additive to the predictive utility of the CHADS2 and CHA2DS2-VASc scores, and in some cases allow for additional risk prognostication of the broad categories allocated by CHADS2 and CHA2DS2-VASc scores of low, medium, and high. SUMMARY Across the spectrum of cerebral injuries in patients with atrial fibrillation, biomarkers hold the promise of personalized risk stratification and management to minimize risks of disease.
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8
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Ito T, Suwa M. Left atrial spontaneous echo contrast: relationship with clinical and echocardiographic parameters. Echo Res Pract 2019; 6:R65-R73. [PMID: 30959476 PMCID: PMC6499934 DOI: 10.1530/erp-18-0083] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/03/2019] [Indexed: 12/19/2022] Open
Abstract
Spontaneous echo contrast (SEC) indicates blood stasis in cardiac chambers and major vessels, and is a known precursor of thrombus formation. Transesophageal echocardiography plays a pivotal role in detecting and grading SEC in the left atrial (LA) cavity. Assessing LA SEC can identify patients at increased risk for thromboembolic events. LA SEC also develops in patients who have sinus rhythm, especially in those with heart failure. Detection of LA SEC is not uncommon in subjects who have multiple cardiovascular comorbidities, although mechanisms behind this association are not fully understood. In patients with atrial fibrillation, the role of mitral regurgitation in counteracting LA SEC and subsequent thromboembolism is controversial. Moreover, alterations of blood coagulability and elevated levels of certain biological markers in the blood contribute to occurrence of LA SEC. This review describes the pathogenesis and assessment of SEC, in addition to the relationship between LA SEC and clinical, biological and echocardiographic parameters.
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Affiliation(s)
- Takahide Ito
- Department of Cardiology, Osaka Medical College, Takatsuki, Japan
| | - Michihiro Suwa
- Department of Cardiovascular Medicine, Hokusetsu General Hospital, Takatsuki, Japan
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9
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Doukky R, Donenberg MJ, Parker J, Kaplan J, Travers C, Soble JS, Sattar P, Krishnan K, Madias C, Tracy M, Feinstein SB. Use of ultrasound enhancing agents in transesophageal echocardiography to improve interpretive confidence of left atrial appendage thrombus. Echocardiography 2018; 36:362-369. [DOI: 10.1111/echo.14228] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 11/01/2018] [Accepted: 11/18/2018] [Indexed: 12/18/2022] Open
Affiliation(s)
- Rami Doukky
- Division of CardiologyCook County Health Chicago Illinois
- Division of CardiologyRush University Medical Center Chicago Illinois
| | | | - Jeremy Parker
- Division of CardiologyRush University Medical Center Chicago Illinois
| | - Jonathan Kaplan
- Division of CardiologyRush University Medical Center Chicago Illinois
| | - Chad Travers
- Division of CardiologyRush University Medical Center Chicago Illinois
| | - Jeffrey S. Soble
- Division of CardiologyRush University Medical Center Chicago Illinois
| | - Payman Sattar
- Division of CardiologyCook County Health Chicago Illinois
- Division of CardiologyRush University Medical Center Chicago Illinois
| | - Kousik Krishnan
- Division of CardiologyRush University Medical Center Chicago Illinois
| | | | - Melissa Tracy
- Division of CardiologyRush University Medical Center Chicago Illinois
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10
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Khan AA, Lip GYH. The prothrombotic state in atrial fibrillation: pathophysiological and management implications. Cardiovasc Res 2018; 115:31-45. [DOI: 10.1093/cvr/cvy272] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 10/30/2018] [Indexed: 02/06/2023] Open
Abstract
AbstractAtrial fibrillation (AF) is the commonest sustained cardiac arrhythmia and is associated with significant morbidity and mortality. There is plenty of evidence available to support the presence of a prothrombotic or hypercoagulable state in AF, but the contributory factors are multifactorial and cannot simply be explained by blood stasis. Abnormal changes in atrial wall (anatomical and structural, as ‘vessel wall abnormalities’), the presence of spontaneous echo contrast to signify abnormal changes in flow and stasis (‘flow abnormalities’), and abnormal changes in coagulation, platelet, and other pathophysiologic pathways (‘abnormalities of blood constituents’) are well documented in AF. The presence of these components therefore fulfils Virchow’s triad for thrombogenesis. In this review, we present an overview of the established and professed pathophysiological mechanisms for thrombogenesis in AF and its management implications.
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Affiliation(s)
- Ahsan A Khan
- Institute of Cardiovascular Sciences, University of Birmingham, City Hospital, Dudley Road, Birmingham, UK
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, City Hospital, Dudley Road, Birmingham, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
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11
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Tanaka S, Hirai T, Inao K, Fukuda N, Nakagawa K, Inoue H, Kinugawa K. High Cardiac Troponin I Is Associated With Transesophageal Echocardiographic Risk of Thromboembolism and Ischemic Stroke Events in Non-Valvular Atrial Fibrillation Patients. Circ J 2018; 82:1699-1704. [PMID: 29607894 DOI: 10.1253/circj.cj-17-1238] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Abnormalities in the left atrium (LA) detected on transesophageal echocardiography (TEE) are reliable predictors of thromboembolism in patients with atrial fibrillation (AF). Cardiac troponin I, a marker of subclinical myocardial damage, may also be a predictor of thromboembolic events in patients with AF. The relationship between cardiac troponin I and thromboembolic risk on TEE, however, remains unclear.Methods and Results:TEE and laboratory data, including high sensitivity cardiac troponin I (hs-cTnI) and CHA2DS2-VASc score, were analyzed in 199 patients with non-valvular AF (NVAF). Patients were stratified into those with or without LA abnormality, defined as LA appendage flow velocity <20 cm/s or dense spontaneous echo contrast. On multiple logistic analysis of the clinical variables, hs-cTnI was associated with LA abnormality (95% CI: 1.0003-1.020, P=0.034). The area under the curve for LA abnormality increased on addition of hs-cTnI to CHA2DS2-VASc score. The incidence rate of ischemic stroke was higher in the high hs-cTnI group than in the low-hs-cTnI group (log-rank test, P<0.05). CONCLUSIONS Elevated hs-cTnI was independently associated with LA abnormality in NVAF patients. hs-cTnI level may be a useful biomarker for risk stratification of thromboembolism in NVAF patients.
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Affiliation(s)
- Shuhei Tanaka
- Second Department of Internal Medicine, University of Toyama
| | - Tadakazu Hirai
- Second Department of Internal Medicine, University of Toyama
| | - Kyoko Inao
- Second Department of Internal Medicine, University of Toyama
| | - Nobuyuki Fukuda
- Second Department of Internal Medicine, University of Toyama
| | - Keiko Nakagawa
- Second Department of Internal Medicine, University of Toyama
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12
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Zhan Y, Joza J, Al Rawahi M, Barbosa RS, Samuel M, Bernier M, Huynh T, Thanassoulis G, Essebag V. Assessment and Management of the Left Atrial Appendage Thrombus in Patients With Nonvalvular Atrial Fibrillation. Can J Cardiol 2018; 34:252-261. [DOI: 10.1016/j.cjca.2017.12.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 12/04/2017] [Accepted: 12/11/2017] [Indexed: 01/14/2023] Open
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Hu XF, Zhan R, Xu S, Wang J, Wu J, Liu X, Li Y, Chen L. Growth differentiation factor 15 is associated with left atrial/left atrial appendage thrombus in patients with nonvalvular atrial fibrillation. Clin Cardiol 2018; 41:34-38. [PMID: 29363835 DOI: 10.1002/clc.22844] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 10/20/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND There is evidence suggesting that growth differentiation factor 15 (GDF-15) appears to be associated with stroke in patients with atrial fibrillation (AF). AF-related thromboembolic stroke is predominantly attributed to the thrombus from the left atrium (LA) or left atrial appendage (LAA). HYPOTHESIS GDF-15 is related to LA/LAA thrombus in nonvalvular AF (NVAF) patients. METHODS A total of 894 patients with NVAF without anticoagulation therapy were included in this study. All patients routinely underwent transesophageal echocardiography for detection of LA/LAA thrombus. GDF-15 was measured by enzyme-linked immunosorbent assay. Logistic regression models were used to test for association. RESULTS LA/LAA thrombus was detected by transesophageal echocardiography in 69 (7.72%) patients with AF. The GDF-15 levels in the patients with LA/LAA thrombus were significantly higher than those without LA/LAA thrombus (log10 GDF-15: 2.989 ± 0.023 ng/L vs 2.831 ± 0.007 ng/L; P < 0.001). Logistic regression analysis showed that GDF-15 was an independent risk factor for LA/LAA thrombus (odds ratio [per quarter]: 1.799, 95% confidence interval: 1.381-2.344, P < 0.001) after adjusting for potential clinical risk factors. The optimal cutoff point for GDF-15 predicting LA/LAA thrombus was 809.9 ng/L (sensitivity, 75.3%; specificity, 61.5%), determined by ROC curve. The area under the curve was 0.709 (95% confidence interval: 0.644-0.770, P < 0.001). CONCLUSIONS Elevated GDF-15 indicated a significantly increased risk for LA/LAA thrombus in NVAF patients. Thus, GDF-15 might be a potentially useful adjunct in discriminating LA/LAA thrombus in NVAF patients.
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Affiliation(s)
- Xiao Feng Hu
- Department of Cardiology, Zhejiang Hospital, Hangzhou, Zhejiang Province, China
| | - Rui Zhan
- Department of Cardiology, Jiangxi Provincial People's Hospital, Nanchang, Jiangxi Province, China
| | - Shanhu Xu
- Department of Neurology, Zhejiang Hospital, Hangzhou, Zhejiang Province, China
| | - Junjun Wang
- Department of Neurology, Zhejiang Hospital, Hangzhou, Zhejiang Province, China
| | - Jiong Wu
- Department of Neurology, Zhejiang Hospital, Hangzhou, Zhejiang Province, China
| | - Xiaoli Liu
- Department of Neurology, Zhejiang Hospital, Hangzhou, Zhejiang Province, China
| | - Yaguo Li
- Department of Neurology, Zhejiang Hospital, Hangzhou, Zhejiang Province, China
| | - Linhui Chen
- Department of Neurology, Zhejiang Hospital, Hangzhou, Zhejiang Province, China
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Correlation between plasma brain natriuretic peptide levels and left atrial appendage flow velocity in patients with non-valvular atrial fibrillation and normal left ventricular systolic function. J Echocardiogr 2017; 16:72-80. [PMID: 29256043 DOI: 10.1007/s12574-017-0362-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 11/27/2017] [Accepted: 11/30/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND The left atrial appendage (LAA) flow velocity is an important factor for thrombus formation in patients with non-valvular atrial fibrillation (NV-AF). Recently, the relation of plasma brain natriuretic peptide (BNP) levels and thromboembolism has been reported in patients with NV-AF. The aim of this study was to determine whether the plasma BNP is predictive of lower LAA flow velocity in patients with NV-AF and normal left ventricular (LV) systolic function. METHODS AND RESULTS A total of 184 patients with NV-AF (132 men; 65 ± 12 years, LV ejection fraction; 65 ± 10%) underwent transthoracic echocardiography, transesophageal echocardiography (TEE), and measurement of plasma BNP. The LAA flow velocity was obtained by pulsed Doppler TEE. Multivariate logistic regression analysis demonstrated that plasma BNP levels, left atrial volume index (LAVI), LV mass index (LVMI), and the CHADS2 score were independent predictors of lower LAA flow velocity (< 20 cm/s). Plasma BNP levels (r = - 0.58, p < 0.001) were correlated with LAA flow velocity. The area under the curve (AUC) for BNP (AUC 0.803) was larger than that for the CHADS2 score (AUC 0.712), LAVI (AUC 0.664) and LVMI (AUC 0.608) with an optimal BNP cut-off value of 164 pg/ml (sensitivity 75.7%, specificity 71.1%). CONCLUSIONS This study showed that a higher plasma BNP was associated with a lower LAA flow velocity in patients with NV-AF and normal LV systolic function. The plasma BNP may complement the role of the CHADS2 score in predicting lower LAA flow velocity.
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Maruyama K, Uchiyama S, Shiga T, Iijima M, Ishizuka K, Hoshino T, Kitagawa K. Brain Natriuretic Peptide Is a Powerful Predictor of Outcome in Stroke Patients with Atrial Fibrillation
. Cerebrovasc Dis Extra 2017; 7:35-43. [PMID: 28253498 PMCID: PMC5465753 DOI: 10.1159/000457808] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 01/10/2017] [Indexed: 01/25/2023] Open
Abstract
Background Since stroke patients with nonvalvular atrial fibrillation (NVAF) have poor outcomes in general, the prediction of outcomes following discharge is of utmost concern for these patients. We previously reported that brain natriuretic peptide (BNP) levels were significantly higher in NVAF patients with larger infarcts, higher modified Rankin Scale (mRS) score, and higher CHADS2 score. In the present study, we evaluated an array of variables, including BNP, in order to determine significant predictors for functional outcome in patients with NVAF after acute ischemic stroke (AIS). Methods A total of 615 consecutive patients with AIS within 48 h of symptom onset, admitted to our hospital between April 2010 and October 2015, were retrospectively searched. Among these patients, we enrolled consecutive patients with NVAF. We evaluated the mRS score 3 months after onset of stroke and investigated associations between mRS score and the following clinical and echocardiographic variables. Categorical variables included male sex, current smoking, alcohol intake, hypertension, diabetes mellitus, dyslipidemia, coronary artery disease, peripheral artery disease, use of antiplatelet drugs, anticoagulants, or tissue plasminogen activator (tPA), and infarct size. Continuous variables included age, systolic blood pressure (SBP), diastolic blood pressure, hemoglobin, creatinine, D-dimer, brain natriuretic peptide (BNP), left atrial diameter, left ventricular ejection fraction (EF), and early mitral inflow velocity/diastolic mitral annular velocity (E/e’). We also analyzed the association of prestroke CHADS2, CHA2DS2-VASc, and R2CHADS2 scores, and National Institutes of Health Stroke Scale (NIHSS) score on admission with mRS score 3 months after the onset of stroke. Patients were classified into 2 groups according to mRS score: an mRS score ≤2 was defined as good outcome, an mRS score ≥3 was defined as poor outcome. To clarify the correlations between categorical or continuous variables and mRS score, uni- and multivariate logistic regression models using the stepwise variable selection method were applied. Results Among 157 patients with NVAF after AIS, 63.7% were male and the mean age was 75.9 years. In univariate regression analysis, poor outcome (mRS score ≥3) was associated with use of tPA, infarct size, age, SBP, BNP, EF, and NIHSS score. In multivariate regression analysis, BNP levels (odds ratio [OR] 6.40; 95% confidence interval [CI] 1.26–32.43; p = 0.0235) and NIHSS score (OR 2.87; 95% CI 1.84–4.47; p < 0.001) were significantly associated with poor outcome (mRS score ≥3) after adjusting for use of tPA, infarct size, age, BNP, EF, and NIHSS score. Conclusions Apart from NIHSS score, BNP was a very useful predictor for long-term outcomes of patients with NVAF after AIS.
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Affiliation(s)
- Kenji Maruyama
- Department of Neurology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Shinichiro Uchiyama
- Department of Neurology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Clinical Research Center, International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo, Japan
| | - Tsuyoshi Shiga
- Department of Cardiology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Mutsumi Iijima
- Department of Neurology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Kentaro Ishizuka
- Department of Neurology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Takao Hoshino
- Department of Neurology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Kazuo Kitagawa
- Department of Neurology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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Doukky R, Garcia-Sayan E, Pant R, Patel M. Authors' Reply. J Am Soc Echocardiogr 2017; 30:198-200. [DOI: 10.1016/j.echo.2016.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Indexed: 10/20/2022]
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17
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Kawabata M, Goya M, Sasaki T, Maeda S, Shirai Y, Nishimura T, Yoshitake T, Shiohira S, Isobe M, Hirao K. Left Atrial Appendage Thrombi Formation in Japanese Non-Valvular Atrial Fibrillation Patients During Anticoagulation Therapy ― Warfarin vs. Direct Oral Anticoagulants ―. Circ J 2017; 81:645-651. [DOI: 10.1253/circj.cj-16-1089] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Masahiko Goya
- Heart Rhythm Center, Tokyo Medical and Dental University
| | - Takeshi Sasaki
- Heart Rhythm Center, Tokyo Medical and Dental University
| | - Shingo Maeda
- Heart Rhythm Center, Tokyo Medical and Dental University
| | | | | | | | | | - Mitsuaki Isobe
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Kenzo Hirao
- Heart Rhythm Center, Tokyo Medical and Dental University
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Derivation and validation of E/e′ ratio as a parameter in the evaluation of left atrial appendage thrombus formation in patients with nonvalvular atrial fibrillation. Int J Cardiovasc Imaging 2016; 32:1349-1356. [DOI: 10.1007/s10554-016-0916-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 05/21/2016] [Indexed: 01/20/2023]
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19
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Bejinariu AG, Härtel DU, Brockmeier J, Oeckinghaus R, Herzer A, Tebbe U. Left atrial thrombi and spontaneous echo contrast in patients with atrial fibrillation : Systematic analysis of a single-center experience. Herz 2016; 41:706-714. [PMID: 27100878 DOI: 10.1007/s00059-016-4423-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 01/30/2016] [Accepted: 02/14/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Atrial fibrillation is associated with a high risk for thromboembolic events. Thrombi in the left atrial appendage and spontaneous echo contrast (SEC) correlate positively with this embolic risk. We studied the laboratory, echocardiographic, and epidemiologic parameters that could predict left atrial thrombi and the intensity of the SEC. PATIENTS AND METHODS Between September 2013 and June 2015 we included 372 patients with atrial fibrillation before planned electrical cardioversion (transesophageal-guided strategy) in this study. After assessing the risk of stroke and bleeding (CHA2DS2-VASc and HAS-BLED scores), we measured the concentration of the D-dimer and B-type natriuretic peptide at the time of the transesophageal echocardiography as well as the left atrial volume and the ejection fraction during transthoracic echocardiography. RESULTS The ejection fraction and the CHA2DS2-VASc score were identified as independent predictors of both left atrial thrombi and SEC, whereas the left atrial volume could only predict the intensity of SEC. In contrast to the results of other studies, the biomarkers in this study failed to predict the outcome. CONCLUSION Only the echocardiographic and epidemiologic parameters were predictors of left atrial thrombi and SEC intensity, while the studied biomarkers had no predictive power. Using clinical data and transthoracic echocardiography, we can change the therapeutic strategy in high-risk patients.
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Affiliation(s)
- A G Bejinariu
- Clinic for Cardiology, Angiology and Intensive Care, Klinikum Lippe Detmold, Röntgenstr. 18, 32756, Detmold, Germany.
| | - D U Härtel
- Clinic for Cardiology, Angiology and Intensive Care, Klinikum Lippe Detmold, Röntgenstr. 18, 32756, Detmold, Germany
| | - J Brockmeier
- Clinic for Cardiology, Angiology and Intensive Care, Klinikum Lippe Detmold, Röntgenstr. 18, 32756, Detmold, Germany
| | - R Oeckinghaus
- Clinic for Cardiology, Angiology and Intensive Care, Klinikum Lippe Detmold, Röntgenstr. 18, 32756, Detmold, Germany
| | - A Herzer
- Clinic for Cardiology, Angiology and Intensive Care, Klinikum Lippe Detmold, Röntgenstr. 18, 32756, Detmold, Germany
| | - U Tebbe
- Clinic for Cardiology, Angiology and Intensive Care, Klinikum Lippe Detmold, Röntgenstr. 18, 32756, Detmold, Germany
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21
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Doukky R, Garcia-Sayan E, Patel M, Pant R, Wassouf M, Shah S, D'Silva O, Kehoe RF. Impact of Diastolic Function Parameters on the Risk for Left Atrial Appendage Thrombus in Patients with Nonvalvular Atrial Fibrillation: A Prospective Study. J Am Soc Echocardiogr 2016; 29:545-53. [PMID: 27021354 DOI: 10.1016/j.echo.2016.01.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND In patients with nonvalvular atrial fibrillation (NVAF), the impact of left ventricular diastolic function on the risk for left atrial appendage (LAA) thrombus has not been prospectively studied. METHODS At two academic medical centers, patients with NVAF were prospectively enrolled to undergo investigational transthoracic echocardiography immediately before clinically indicated transesophageal echocardiography. Mitral inflow E velocity and tissue Doppler septal and lateral mitral annulus velocities (e') were measured, and E/e' ratios were calculated. RESULTS Among 266 subjects (mean age, 65 years; 32% women), 17 (6.4%) had LAA thrombus. Patients with LAA thrombus had a higher mean CHA2DS2-VASc score (4.6 ± 1.7 vs 3.0 ± 1.8, P < .001), a higher mean lateral E/e' ratio (19.4 ± 10.1 vs 10.2 ± 5.6, P < .001), and a lower mean lateral e' velocity (7.0 ± 3.2 vs 10.4 ± 3.7 cm/sec, P = .001). There was a good discriminative capacity for E/e' (area under the curve, 0.83; P < .001) and e' velocity (area under the curve, 0.76; P = .001). None of the patients with normal E/e' ratios or normal e' velocities had LAA thrombus. Both E/e' (odds ratio, 1.13 per point; 95% CI, 1.06-1.20; P < .001) and e' velocity (odds ratio, 0.76 per 1 cm/sec; 95% CI, 0.63-0.92; P = .005) provided independent and incremental predictive value beyond the CHA2DS2-VASc score; however, E/e' provided greater incremental value than e' velocity (P = .036). Analyses using septal and averaged E/e' and septal e' velocity yielded similar results. Diastolic function parameters were also associated with the presence and intensity of left atrial spontaneous echo contrast, a precursor of LAA thrombus. CONCLUSIONS This prospective and concomitant evaluation of diastolic function and LAA thrombus in patients with NVAF demonstrates that E/e' ratio and e' velocity are associated with LAA thrombus, independent of CHA2DS2-VASc score, and may play a role in identifying patients at low risk for LAA thrombus. These data suggest that diastolic function assessment may improve stroke prediction in patients with NVAF.
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Affiliation(s)
- Rami Doukky
- Division of Adult Cardiology, John H. Stroger, Jr Hospital of Cook County, Chicago, Illinois; Division of Cardiology, Rush University Medical Center, Chicago, Illinois.
| | - Enrique Garcia-Sayan
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois; Division of Cardiology, Mount Sinai Hospital, Chicago, Illinois
| | - Mita Patel
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois; Division of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rojina Pant
- Division of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois
| | - Marwan Wassouf
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois; Department of Medicine, Fairview Hospital, Cleveland, Ohio
| | - Saurabh Shah
- Division of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois
| | - Oliver D'Silva
- Division of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois
| | - Richard F Kehoe
- Division of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois
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Pant R, Patel M, Garcia-Sayan E, Wassouf M, D'Silva O, Kehoe RF, Doukky R. Impact of B-type natriuretic peptide level on the risk of left atrial appendage thrombus in patients with nonvalvular atrial fibrillation: a prospective study. Cardiovasc Ultrasound 2016; 14:4. [PMID: 26772738 PMCID: PMC4715322 DOI: 10.1186/s12947-016-0047-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 01/12/2016] [Indexed: 01/20/2023] Open
Abstract
Background The impact of B-type natriuretic peptide (BNP) level on the risk of left atrial appendage (LAA) thrombus in patients with nonvalvular atrial fibrillation (NVAF) has not been prospectively studied. Methods In two academic medical centers, we obtained BNP levels immediately prior to transesophageal echocardiogram performed to exclude LAA thrombus in patients with NVAF. Results Among 261 subjects (mean age 65 ± 12 years; 30 % women) with NVAF, 17 (6.5 %) had LAA thrombus and 85 (32.6 %) had at least mild spontaneous echo contrast (SEC). Mean BNP level was significantly higher in patients with LAA thrombus [775 ± 678 vs. 384 ± 537, P = 0.001]. Receiver operator characteristics analysis demonstrated that BNP has a good discriminatory capacity for LAA thrombus (area under the curve, 0.74; 95 % confidence interval [CI], 0.63–0.85; P = 0.001); BNP ≥ 67 pg/mL was 100 % sensitive and 20 % specific for LAA thrombus. Multivariate logistic regression analysis demonstrated that BNP was not independently associated with LAA thrombus (odds-ratio, 1.05 per 100 pg/mL increment; CI, 0.99–1.12; P = 0.127) after adjusting for CHA2DS2-VASc score; while the latter was independently associated with LAA thrombus after adjusting for BNP level (odds-ratio, 1.46 per CHA2DS2-VASc point; CI, 1.09–1.96; P = 0.011). Nonetheless, BNP was associated with SEC in univariate and multivariate analysis, after adjusting for the CHA2DS2-VASc score, (odds-ratio, 1.08; CI, 1.02–1.14; P = 0.005). Conclusions BNP is predictive of SEC. However, it does not provide significant incremental value in the prediction of LAA thrombus.
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Affiliation(s)
- Rojina Pant
- Division of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Mita Patel
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.,Division of Cardiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Enrique Garcia-Sayan
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.,Division of Cardiology, Mount Sinai Hospital, Chicago, IL, USA
| | - Marwan Wassouf
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.,Department of Medicine, Fairview Hospital, Cleveland, OH, USA
| | - Oliver D'Silva
- Division of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Richard F Kehoe
- Division of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Rami Doukky
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA. .,Division of Adult Cardiology, John H. Stroger, Jr. Hospital of Cook County, 1901 W. Harrison St, Chicago, IL, 60612, USA.
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Asymmetric dimethylarginine predicts left atrial appendage thrombus in patients with non-valvular atrial fibrillation. Thromb Res 2015; 136:1156-9. [DOI: 10.1016/j.thromres.2015.10.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 10/08/2015] [Accepted: 10/09/2015] [Indexed: 11/21/2022]
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Di Minno MND, Ambrosino P, Dello Russo A, Casella M, Tremoli E, Tondo C. Prevalence of left atrial thrombus in patients with non-valvular atrial fibrillation. A systematic review and meta-analysis of the literature. Thromb Haemost 2015; 115:663-77. [PMID: 26607276 DOI: 10.1160/th15-07-0532] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 10/22/2015] [Indexed: 11/05/2022]
Abstract
We performed a meta-analysis about the prevalence of left atrial thrombus (LAT) in patients with atrial fibrillation (AF) undergoing trans-esophageal echocardiography (TEE). Studies reporting on LAT presence in AF patients were systematically searched in the PubMed, Web of Science, Scopus and EMBASE databases and the pooled LAT prevalence was evaluated as weighted mean prevalence (WMP). Seventy-two studies (20,516 AF patients) showed a LAT WMP of 9.8 % (95 %CI: 7.6 %-12.5 %). LAT presence was associated with a higher age (mean difference: 2.56, 95 %CI: 1.49-3.62), and higher prevalence of female gender (OR: 1.35, 95 %CI: 1.04-1.75), hypertension (OR: 1.78, 95 %CI: 1.38-2.30), diabetes mellitus (OR: 1.86, 95 %CI: 1.33-2.59) and chronic heart failure (OR: 3.67, 95 %CI: 2.40-5.60). Overall, LAT patients exhibited a higher CHADS2-score (mean difference 0.88, 95 %CI: 0.68-1.07) and a higher risk of stroke/systemic embolism (OR: 3.53, 95 %CI: 2.24-5.56) compared with those without LAT. A meta-regression showed an inverse association between LAT prevalence and the presence of anticoagulation (Z-value: -7.3, p< 0.001). Indeed, studies in which 100 % of patients received oral anticoagulation reported a 3.4 % WMP of LAT (95 %CI: 1.3 %-8.7 %), whereas studies in which 0 % of patients received anticoagulation showed a LAT WMP of 7.4 % (95 %CI: 2.3 %-21.5 %). Our data suggest that LAT is present in ≍10 % of AF patients, and is associated with a 3.5-fold increased risk of stroke/systemic embolism. Interestingly, LAT is also reported in some of patients receiving anticoagulation. The implementation of the screening of LAT in AF patients before cardioversion/ablation could be useful for the prevention of vascular events.
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Affiliation(s)
- Matteo Nicola Dario Di Minno
- Matteo Nicola Dario Di Minno, MD, PhD, Unit of Cell and Molecular Biology in Cardiovascular Diseases, Centro Cardiologico Monzino, IRCCS, Via C. Parea 4, 20138 Milan, Italy, Tel./Fax: +39 02 58002857, E-mail:
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Ochiumi Y, Kagawa E, Kato M, Sasaki S, Nakano Y, Itakura K, Takiguchi Y, Ikeda S, Dote K. Usefulness of brain natriuretic peptide for predicting left atrial appendage thrombus in patients with unanticoagulated nonvalvular persistent atrial fibrillation. J Arrhythm 2015; 31:307-12. [PMID: 26550088 DOI: 10.1016/j.joa.2015.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 04/02/2015] [Accepted: 04/06/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The CHADS2 scoring system is simple and widely accepted for predicting thromboembolism in patients with nonvalvular atrial fibrillation (NVAF). Although congestive heart failure (CHF) is a component of the CHADS2 score, the definition of CHF remains unclear. We previously reported that the presence of CHF was a strong predictor of left atrial appendage (LAA) thrombus. Therefore, the present study aimed to elucidate the relationship between LAA thrombus and the brain natriuretic peptide (BNP) level in patients with unanticoagulated NVAF. METHODS The study included 524 consecutive patients with NVAF who had undergone transesophageal echocardiography to detect intracardiac thrombus before cardioversion between January 2006 and December 2008, at Hiroshima City Asa Hospital. The exclusion criteria were as follows: paroxysmal atrial fibrillation, unknown BNP levels, prothrombin time international normalized ratio ≥2.0, and hospitalization for systemic thromboembolism. RESULTS Receiver operating characteristic analysis yielded optimal plasma BNP cut-off levels of 157.1 pg/mL (area under the curve, 0.91; p<0.01) and 251.2 pg/mL (area under the curve, 0.70; p<0.01) for identifying CHF and detecting LAA thrombus, respectively. Multivariate analyses demonstrated that a BNP level >251.2 pg/mL was an independent predictor of LAA thrombus (odds ratio, 3.51; 95% confidence interval, 1.08-10.7; p=0.046). CONCLUSIONS In patients with unanticoagulated NVAF, a BNP level >251.2 pg/mL may be helpful for predicting the incidence of LAA thrombus and may be used as a surrogate marker of CHF. The BNP level is clinically useful for the risk stratification of systemic thromboembolism in patients with unanticoagulated NVAF.
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Key Words
- AUC, area under the curve
- Atrial fibrillation
- BNP, brain natriuretic peptide
- Brain natriuretic peptide
- CHF, congestive heart failure
- EF, ejection fraction
- Heart failure
- LAA, left atrial appendage
- Left atrial appendage thrombus
- NVAF, nonvalvular atrial fibrillation
- NYHA, New York Heart Association
- PT-INR, prothrombin time international normalized ratio
- ROC, receiver operating characteristic
- TEE, transesophageal echocardiography
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Affiliation(s)
- Yusuke Ochiumi
- Department of Cardiology, Hiroshima City Asa Hospital, Hiroshima, Japan
| | - Eisuke Kagawa
- Department of Cardiology, Hiroshima City Asa Hospital, Hiroshima, Japan
| | - Masaya Kato
- Department of Cardiology, Hiroshima City Asa Hospital, Hiroshima, Japan
| | - Shota Sasaki
- Department of Cardiology, Hiroshima City Asa Hospital, Hiroshima, Japan
| | - Yoshinori Nakano
- Department of Cardiology, Hiroshima City Asa Hospital, Hiroshima, Japan
| | - Kiho Itakura
- Department of Cardiology, Hiroshima City Asa Hospital, Hiroshima, Japan
| | - Yu Takiguchi
- Department of Cardiology, Hiroshima City Asa Hospital, Hiroshima, Japan
| | - Shuntaro Ikeda
- Department of Cardiology, City Uwajima Hospital, Ehime, Japan
| | - Keigo Dote
- Department of Cardiology, Hiroshima City Asa Hospital, Hiroshima, Japan
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Abstract
Percutaneous left atrial appendage (LAA) closure is being increasingly used as a treatment strategy to prevent stroke in patients with atrial fibrillation (AF) who have contraindications to anticoagulants. Several approaches and devices have been developed in the last few years, each with their own unique set of advantages and disadvantages. In this article, the published studies on surgical and percutaneous approaches to LAA closure are reviewed, focusing on stroke mechanisms in AF, LAA structure and function relevant to stroke prevention, practical differences in procedural approach, and clinical considerations surrounding management.
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Affiliation(s)
- Faisal F Syed
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Christopher V DeSimone
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Paul A Friedman
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Pediatrics and Adolescent Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Kanmanthareddy A, Reddy YM, Vallakati A, Earnest MB, Nath J, Ferrell R, Dawn B, Lakkireddy D. Embryology and Anatomy of the Left Atrial Appendage: Why Does Thrombus Form? Interv Cardiol Clin 2014; 3:191-202. [PMID: 28582164 DOI: 10.1016/j.iccl.2013.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The left atrial appendage (LAA) is a long tubular structure that opens into the left atrium. In patients with atrial fibrillation, the LAA develops mechanical dysfunction and fibroelastotic changes on the endocardial surface. The complex anatomy of the LAA makes it a good site for relative blood stasis. In addition, systemic factors exacerbate the hypercoagulable state, eventually resulting in endothelial dysfunction, release of tissue factor, and production of inflammatory cytokines and oxidative free radicals, and eventually initiating the coagulation cascade. Thus, the LAA is susceptible to thrombus formation and is the most common source of systemic thromboembolism.
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Affiliation(s)
- Arun Kanmanthareddy
- Division of Cardiovascular Medicine, Mid-America Cardiology, University of Kansas Hospital, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Yeruva Madhu Reddy
- Division of Cardiovascular Medicine, University of Kansas Hospital, Kansas City, KS 66160, USA
| | - Ajay Vallakati
- Division of Cardiology, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH 44109, USA
| | - Matthew B Earnest
- Mid-America Cardiology, University of Kansas Hospital, Kansas City, KS 66160, USA
| | - Jayant Nath
- Division of Cardiovascular Medicine, Mid-America Cardiology, University of Kansas Hospital, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Ryan Ferrell
- Division of Cardiovascular Medicine, Mid-America Cardiology, University of Kansas Hospital, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Buddhadeb Dawn
- Division of Cardiovascular Medicine, Mid-America Cardiology, University of Kansas Hospital, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Dhanunjaya Lakkireddy
- Division of Cardiology, Mid-America Cardiology, Center for Excellence in Atrial Fibrillation & Electrophysiology Research, Bloch Heart Rhythm Center, KU Cardiovascular Research Institute, University of Kansas Hospital, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA.
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Doukky R, Garcia-Sayan E, Gage H, Nagarajan V, Demopoulos A, Cena M, Nazir NT, Karam GJ, Trohman RG, Kazlauskaite R. The value of diastolic function parameters in the prediction of left atrial appendage thrombus in patients with nonvalvular atrial fibrillation. Cardiovasc Ultrasound 2014; 12:10. [PMID: 24568305 PMCID: PMC3937435 DOI: 10.1186/1476-7120-12-10] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 02/17/2014] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Left ventricular diastolic impairment and consequently elevated filling pressure may contribute to stasis leading to left atrial appendage thrombus (LAAT) in nonvalvular atrial fibrillation (AF). We investigated whether transthoracic echocardiographic parameters can predict LAAT independent of traditional clinical predictors. METHODS We conducted a retrospective cohort study of 297 consecutive nonvalvular AF patients who underwent transthoracic echocardiogram followed by a transesophageal echocardiogram within one year. Multivariate logistic regression analysis models were used to determine factors independently associated with LAAT. RESULTS Nineteen subjects (6.4%) were demonstrated to have LAAT by transesophageal echocardiography. These patients had higher mean CHADS2 scores [2.6 ± 1.2 vs. 1.9 ± 1.3, P = 0.009], higher E:e' ratios [16.6 ± 6.1 vs. 12.0 ± 5.4, P = 0.001], and lower mean e' velocities [6.5 ± 2.1 cm/sec vs. 9.1 ± 3.2 cm/sec, P = 0.001]. Both E:e' and e' velocity were associated with LAAT formation independent of the CHADS2 score, warfarin therapy, left ventricular ejection fraction (LVEF), and left atrial volume index (LAVI) [E:e' odds-ratio = 1.14 (95% confidence interval = 1.03 - 1.3), P = 0.009; e' velocity odds-ratio = 0.68 (95% confidence interval = 0.5 - 0.9), P = 0.007]. Similarly, diastolic function parameters were independently associated with spontaneous echo contrast. CONCLUSION The diastolic function indices E:e' and e' velocity are independently associated with LAAT in nonvalvular AF patients and may help identify patients at risk for LAAT.
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Affiliation(s)
- Rami Doukky
- Division of Cardiology, Rush University Medical Center, 1653 W, Congress Pkwy, Chicago, IL 60612, USA.
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Numa S, Hirai T, Nakagawa K, Ohara K, Fukuda N, Nozawa T, Inoue H. Hyperuricemia and Transesophageal Echocardiographic Thromboembolic Risk in Patients With Atrial Fibrillation at Clinically Low-Intermediate Risk. Circ J 2014; 78:1600-5. [DOI: 10.1253/circj.cj-13-1385] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Satoshi Numa
- Second Department of Internal Medicine, University of Toyama
| | - Tadakazu Hirai
- Second Department of Internal Medicine, University of Toyama
| | - Keiko Nakagawa
- Second Department of Internal Medicine, University of Toyama
| | - Kazumasa Ohara
- Second Department of Internal Medicine, University of Toyama
| | - Nobuyuki Fukuda
- Second Department of Internal Medicine, University of Toyama
| | - Takashi Nozawa
- Second Department of Internal Medicine, University of Toyama
| | - Hiroshi Inoue
- Second Department of Internal Medicine, University of Toyama
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Doukky R. Reply. Echocardiography 2013; 30:1122. [DOI: 10.1111/echo.12339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Rami Doukky
- Division of Cardiology; Rush University Medical Center; Chicago Illinois
- Hospital of Cook County; Chicago Illinois
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İşcen S. Comment on B-Type Natriuretic Peptide Predicts Left Atrial Appendage Thrombus in Patients with Nonvalvular Atrial Fibrillation. Echocardiography 2013; 30:1121. [DOI: 10.1111/echo.12338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Sinan İşcen
- Department of Cardiology; Dıyarbakır Mılıtary Hospıtal; Yehişehir Diyarbakır Turkey
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