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Kamili K, Zheng T, Luo C, Wang X, Tian G. Predictive value of lipoprotein(a) for left atrial thrombus or spontaneous echo contrast in non-valvular atrial fibrillation patients with low CHA 2DS 2-VASc scores: a cross-sectional study. Lipids Health Dis 2024; 23:22. [PMID: 38254171 PMCID: PMC10801929 DOI: 10.1186/s12944-023-01990-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/24/2023] [Indexed: 01/24/2024] Open
Abstract
OBJECTIVE Current guidelines are debated when it comes to starting anticoagulant therapy in patients with non-valvular atrial fibrillation (NVAF) and low CHA2DS2-VASc scores (1-2 in women and 0-1 in men). However, these individuals still have a high likelihood of developing left atrial thrombus/spontaneous echo contrast (LAT/SEC) and experiencing subsequent thromboembolism. Recent research has demonstrated that lipoprotein(a) [Lp(a)] may increase the risk of thrombosis, but the relationship between Lp(a) and LAT/SEC in NVAF patients is not clearly established. Therefore, this study sought to evaluate the predictive ability of Lp(a) for LAT/SEC among NVAF patients with low CHA2DS2-VASc scores. METHODS NVAF patients with available transesophageal echocardiography (TEE) data were evaluated. Based on the TEE results, the subjects were classified into non-LAT/SEC and LAT/SEC groups. The risk factors for LAT/SEC were examined using binary logistic regression analyses and were validated by using 1:1 propensity score matching (PSM). Subsequently, novel predictive models for LAT/SEC were developed by integrating the CHA2DS2-VASc score with the identified factors, and the accuracy of these models was tested using receiver operating characteristic (ROC) analysis. RESULTS In total, 481 NVAF patients were enrolled. The LAT/SEC group displayed higher Lp(a) concentrations. It was found that enlarged left atrial diameter (LAD), high concentrations of Lp(a), and a history of coronary heart disease (CHD) were independent predictors of LAT/SEC. Lp(a) and LAD still had predictive values for LAT/SEC after adjusting for PSM. In both the highest quartile groups of Lp(a) (>266 mg/L) and LAD (>39.5 mm), the occurrence of LAT/SEC was higher than that in the corresponding lowest quartile. By incorporating Lp(a) and the LAD, the predictive value of the CHA2DS2-VASc score for LAT/SEC was significantly improved. CONCLUSION Elevated Lp(a) and enlarged LAD were independent risk factors for LAT/SEC among NVAF patients with low CHA2DS2-VASc scores. The prediction accuracy of the CHA2DS2-VASc score for LAT/SEC was significantly improved by the addition of Lp(a) and LAD. When evaluating the stroke risk in patients with NVAF, Lp(a) and LAD should be taken into account together with the CHA2DS2-VASc score. TRIAL REGISTRATION Retrospectively registered.
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Affiliation(s)
- Kamila Kamili
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Rd, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Tingting Zheng
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Rd, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Chaodi Luo
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Rd, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Xuan Wang
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Rd, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Gang Tian
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Rd, Xi'an, Shaanxi, 710061, People's Republic of China.
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Tan CD, Liu JZ, Zheng YP, Li ZJ, Zhou SX. Left atrial enlargement and high uric acid level are risk factors for left atrial thrombus or dense spontaneous echo contrast in atrial fibrillation patients with low to moderate embolic risk assessed by CHA 2DS 2-VAS C score. Front Cardiovasc Med 2023; 10:937770. [PMID: 37465453 PMCID: PMC10351038 DOI: 10.3389/fcvm.2023.937770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/12/2023] [Indexed: 07/20/2023] Open
Abstract
Aims To investigate the correlation and predictive value of left atrial diameter and blood uric acid levels with the occurrence of left atrial thrombus or dense spontaneous echo contrast in atrial fibrillation patients with low to moderate CHA2DS2-VASc scores. Methods and results A total of 849 inpatients diagnosed with atrial fibrillation who had low to moderate CHA2DS2-VASc scores and complete transesophageal echocardiography were included in this study. Among them, 66 patients had left atrial thrombus or dense spontaneous echo contrast. When different models were used to correct other known risk factors, acid levels and abnormal left atrial diameter were identified as additional risk factors for left atrial thrombus or dense spontaneous echo contrast. The incidence of left atrial thrombus or dense spontaneous echo contrast was higher in patients with abnormal serum uric acid levels than in the control group (12.4% vs. 5.6%, p < 0.05), and this difference persisted after correcting the baseline data with propensity score matching (10.6% vs. 4.1%, p < 0.05). Abnormal left atrial diameter was another risk factor suggested by regression analysis, with an increased incidence of left atrial thrombus or dense spontaneous echo contrast in the abnormal left atrial diameter group compared to the control group, both before (18.0% vs. 3.5%, p < 0.05) and after (15.5% vs. 5.2%, p < 0.05) propensity score matching. The best predictive value was obtained by adding both abnormal serum uric acid levels and abnormal left atrial diameter. Conclusion Left atrial enlargement and high uric acid levels increase the risk of left atrial thrombus or dense spontaneous echo contrast in atrial fibrillation patients with low to moderate CHA2DS2-VASc scores.
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Segan L, Nanayakkara S, Spear E, Shirwaiker A, Chieng D, Prabhu S, Sugumar H, Ling L, Kaye DM, Kalman JM, Voskoboinik A, Kistler PM. Identifying Patients at High Risk of Left Atrial Appendage Thrombus Before Cardioversion: The CLOTS-AF Score. J Am Heart Assoc 2023; 12:e029259. [PMID: 37301743 PMCID: PMC10356043 DOI: 10.1161/jaha.122.029259] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/13/2023] [Indexed: 06/12/2023]
Abstract
Background Transesophageal echocardiography-guided direct cardioversion is recommended in patients who are inadequately anticoagulated due to perceived risk of left atrial appendage thrombus (LAAT); however, LAAT risk factors remain poorly defined. Methods and Results We evaluated clinical and transthoracic echocardiographic parameters to predict LAAT risk in consecutive patients with atrial fibrillation (AF)/atrial flutter undergoing transesophageal echocardiography before cardioversion between 2002 and 2022. Regression analysis identified predictors of LAAT, combined to create the novel CLOTS-AF risk score (comprising clinical and echocardiographic LAAT predictors), which was developed in the derivation cohort (70%) and validated in the remaining 30%. A total of 1001 patients (mean age, 62±13 years; 25% women; left ventricular ejection fraction, 49.8±14%) underwent transesophageal echocardiography, with LAAT identified in 140 of 1001 patients (14%) and dense spontaneous echo contrast precluding cardioversion in a further 75 patients (7.5%). AF duration, AF rhythm, creatinine, stroke, diabetes, and echocardiographic parameters were univariate LAAT predictors; age, female sex, body mass index, anticoagulant type, and duration were not (all P>0.05). CHADS2VASc, though significant on univariate analysis (P<0.001), was not significant after adjustment (P=0.12). The novel CLOTS-AF risk model comprised significant multivariable predictors categorized and weighted according to clinically relevant thresholds (Creatinine >1.5 mg/dL, Left ventricular ejection fraction <50%, Overload (left atrial volume index >34 mL/m2), Tricuspid Annular Plane Systolic Excursion (TAPSE) <17 mm, Stroke, and AF rhythm). The unweighted risk model had excellent predictive performance with an area under the curve of 0.820 (95% CI, 0.752-0.887). The weighted CLOTS-AF risk score maintained good predictive performance (AUC, 0.780) with an accuracy of 72%. Conclusions The incidence of LAAT or dense spontaneous echo contrast precluding cardioversion in patients with AF who are inadequately anticoagulated is 21%. Clinical and noninvasive echocardiographic parameters may identify patients at increased risk of LAAT better managed with a suitable period of anticoagulation before undertaking cardioversion.
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Affiliation(s)
- Louise Segan
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Shane Nanayakkara
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- Monash UniversityMelbourneAustralia
| | | | | | - David Chieng
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Sandeep Prabhu
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Hariharan Sugumar
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Liang‐Han Ling
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - David M. Kaye
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- Monash UniversityMelbourneAustralia
| | - Jonathan M. Kalman
- University of MelbourneMelbourneAustralia
- Royal Melbourne HospitalMelbourneAustralia
| | - Aleksandr Voskoboinik
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- Monash UniversityMelbourneAustralia
| | - Peter M. Kistler
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
- Monash UniversityMelbourneAustralia
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Kreimer F, Backhaus JF, Krogias C, Pflaumbaum A, Mügge A, Gotzmann M. P-wave parameters and their association with thrombi and spontaneous echo contrast in the left atrial appendage. Clin Cardiol 2023; 46:397-406. [PMID: 36808747 PMCID: PMC10106666 DOI: 10.1002/clc.23980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 01/07/2023] [Accepted: 01/12/2023] [Indexed: 02/20/2023] Open
Abstract
BACKGROUND The aim of this study was to examine the prevalence of abnormal P-wave parameters in patients with thrombus and/or spontaneous echo contrast (SEC) in the left atrial appendage (LAA), and to identify P-wave parameters particularly associated with thrombus and SEC formation. HYPOTHESIS We presume a significant relationship of P-wave parameters with thrombi and SEC. METHODS All patients in whom a thrombus or SEC was detected in the LAA on transoesophageal echocardiography were included in this study. Patients at risk (CHA2DS2-VASc Score ≥3) and routine transoesophageal echocardiography to exclude thrombi served as the control group. A detailed ECG analysis was performed. RESULTS Of a total of 4062 transoesophageal echocardiographies, thrombi and SEC were detected in 302 patients (7.4%). Of these patients, 27 (8.9%) presented with sinus rhythm. The control group included 79 patients. There was no difference in mean CHA2DS2-VASc score in the two groups (p = .182). A high prevalence of abnormal P-wave parameters was detected in patients with thrombus/SEC. Indicators for the presence of thrombi or SEC in the LAA were P-wave duration >118 ms (Odds ratio (OR) 3.418, Confidence interval (CI) 1.522-7.674, p < .001), P-wave dispersion >40 ms (OR 2.521, CI 1.390-4.571, p < .001) and advanced interatrial block (OR 1.431, CI 1.033-1.984, p = .005). CONCLUSION Our study revealed that several P-wave parameters are associated with thrombi and SEC in the LAA. The results may help identify patients who are at particularly high risk for thromboembolic events (e.g., in patients with embolic stroke of undetermined source).
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Affiliation(s)
- Fabienne Kreimer
- Cardiology and Rhythmology, St Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Julian Felix Backhaus
- Cardiology and Rhythmology, St Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Christos Krogias
- Neurology, St Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Andreas Pflaumbaum
- Cardiology and Rhythmology, St Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Andreas Mügge
- Cardiology and Rhythmology, St Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Michael Gotzmann
- Cardiology and Rhythmology, St Josef-Hospital, Ruhr University Bochum, Bochum, Germany
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Kołakowski K, Farkowski MM, Pytkowski M, Gardziejczyk P, Kowalik I, Dąbrowski R, Firek B, Jaworski K, Klisiewicz A, Maciąg A. The Comparative Effectiveness and Safety of Different Anticoagulation Strategies for Treatment of Left Atrial Appendage Thrombus in the Setting of Chronic Anticoagulation for Atrial Fibrillation or Flutter. Cardiovasc Drugs Ther 2023; 37:159-168. [PMID: 34669102 PMCID: PMC9834361 DOI: 10.1007/s10557-021-07278-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 01/16/2023]
Abstract
PURPOSE To compare effectiveness of different treatments for atrial fibrillation (AF) patients who were scheduled for cardioversion (CV) or ablation (CA) presenting with left atrium appendage (LAA) thrombus despite chronic oral anticoagulation therapy (OAC). METHODS This was a retrospective cohort study. We analyzed 2014-2019 medical records of patients scheduled for CV or CA of AF who were diagnosed with LAA thrombus despite optimal OAC and had a follow-up transesophageal echocardiogram (TOE). Changes in treatment were divided into the following groups: switch to a drug with different mechanism of action, switch to a drug with similar mechanism of action, initiation of combination therapy, or deliberate no change in treatment. Patients with contraindications to non-vitamin K antagonists were excluded from the analysis. RESULTS We analyzed data of 129 patients comprising 181 cycles of treatment. The overall effectiveness of LAA thrombus dissolution was 51.9% regardless of the number of cycles and 42.6% for the first cycle of treatment. Any change of treatment was more effective than deliberate no change-OR 2.97 [95% CI: 1.07-8.25], P = 0.031, but no particular strategy seemed to be more effective than the other. Left atrium area (OR 0.908 [95% CI: 0.842-0.979]) and number of treatment cycles (OR 0.457 [95% CI: 0.239-0.872]) were both adversely related to thrombus resolution. There was one ischemic and three bleeding adverse events during the treatment. CONCLUSION LAA thrombus resolution in patients already on OAC may require a change of previous OAC treatment but the overall effectiveness of dissolution seems to be about 50%.
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Affiliation(s)
- Karol Kołakowski
- II Department of Heart Arrhythmia, National Institute of Cardiology, Alpejska 42, 04-628, Warsaw, Poland
| | - Michał M Farkowski
- II Department of Heart Arrhythmia, National Institute of Cardiology, Alpejska 42, 04-628, Warsaw, Poland.
| | - Mariusz Pytkowski
- II Department of Heart Arrhythmia, National Institute of Cardiology, Alpejska 42, 04-628, Warsaw, Poland
| | - Piotr Gardziejczyk
- II Department of Heart Arrhythmia, National Institute of Cardiology, Alpejska 42, 04-628, Warsaw, Poland
| | - Ilona Kowalik
- Department of Coronary Artery Disease and Cardiac Rehabilitation, National Institute of Cardiology, Warsaw, Poland
| | - Rafał Dąbrowski
- Department of Coronary Artery Disease and Cardiac Rehabilitation, National Institute of Cardiology, Warsaw, Poland
| | - Bohdan Firek
- Department of Coronary Artery Disease and Cardiac Rehabilitation, National Institute of Cardiology, Warsaw, Poland
| | - Krzysztof Jaworski
- Department of Coronary Artery Disease and Cardiac Rehabilitation, National Institute of Cardiology, Warsaw, Poland
| | - Anna Klisiewicz
- Department of Congenital Heart Diseases, National Institute of Cardiology, Warsaw, Poland
| | - Aleksander Maciąg
- II Department of Heart Arrhythmia, National Institute of Cardiology, Alpejska 42, 04-628, Warsaw, Poland
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Liu H, Lin M, Han W, Ge J, Maduray K, Zhong J. The risk factors of thrombus formation and the effect of catheter ablation on repetitive thrombus formation in patients with atrial fibrillation: a single center retrospective study in China. BMC Cardiovasc Disord 2023; 23:28. [PMID: 36650447 PMCID: PMC9843887 DOI: 10.1186/s12872-023-03050-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 01/06/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) predisposes patients to the formation of atrial thrombi. The CHA2DS2-VASc score does not include all risk factors for atrial thrombosis. The present study is designed to explore the influencing factors of thrombus formation in patients with AF and to investigate the effect of catheter ablation (CA) on recurrent thrombosis in patients with a history of intracardiac thrombus. METHODS (1) This study consisted of 1726 patients that underwent CA, among which 58 patients had a history of intracardiac thrombus prior to CA. The risk factors for thrombus formation were explored by comparing the baseline clinical characteristics of patients with and without atrial thrombus. (2) The left atrial appendage flow velocity (LAAFV) in patients with a history of intracardiac thrombus who were willing to undergo transesophageal echocardiography (TEE) at the latest follow-up were examined, and comparisons of the LAAFV was made before and after CA. RESULTS The median follow-up period is 13 months. Persistent AF was found to be the only independent risk factor affecting the formation of atrial thrombus among the investigated factors (OR 3.152; 95%CI 1.806-5.500; p < 0.001). Twenty-seven patients agreed to undergo TEE during follow-up, no clinical ischemic stroke events were recorded, no recurrent intracardiac thrombus formation was detected in patients, 15 patients maintained sinus rhythm (55.6%) during follow-up; successful CA significantly increased LAAFV (difference between latest evaluation prior to CA 17.46 ± 14.81 cm/s, p < 0.001). CONCLUSIONS Persistent AF is the only independent risk factor for thrombus formation. Successful CA may improve the LAAFV and thereby decrease the risk of intracardiac thrombus formation.
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Affiliation(s)
- Huiyu Liu
- grid.452402.50000 0004 1808 3430The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China ,Department of Cardiology, Nanyang Central Hospital, Nanyang, China
| | - Mingjie Lin
- grid.27255.370000 0004 1761 1174Department of Cardiology, Qilu Hospital (Qingdao) of Shandong University, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, 758 Hefei Road, Qingdao, 266035 Shandong China
| | - Wenqiang Han
- grid.452402.50000 0004 1808 3430The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Junye Ge
- grid.452402.50000 0004 1808 3430The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Kellina Maduray
- grid.452402.50000 0004 1808 3430The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Jingquan Zhong
- grid.452402.50000 0004 1808 3430The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China ,grid.27255.370000 0004 1761 1174Department of Cardiology, Qilu Hospital (Qingdao) of Shandong University, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, 758 Hefei Road, Qingdao, 266035 Shandong China
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Yang S, Zhang Y, Chen N, Shi J, Ju W, Chen H, Yang G, Wang Z, Liu H, Jiang X, Cui C, Chen M, Li M. Characteristics, Thrombus Resolution, and Long-Term Outcomes in Patients with Nonvalvular Atrial Fibrillation and Atrial Thrombus. Clin Appl Thromb Hemost 2023; 29:10760296231168097. [PMID: 37079758 PMCID: PMC10126607 DOI: 10.1177/10760296231168097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Abstract
To assess the prevalence and management of atrial thrombus in patients with nonvalvular atrial fibrillation (NVAF) and identify the risk factors of the nonresolution of atrial thrombus. This single-center retrospective observational study consecutively enrolled patients with NVAF and atrial thrombus detected using transesophageal echocardiography (TEE) or cardiac computed tomography angiography (CTA) from January 2012 to December 2020. Patients with prior left atrial appendage (LAA) intervention were excluded. The primary endpoint was the presence of atrial thrombus, while the secondary endpoint was the complete resolution of atrial thrombus. The prevalence of atrial thrombus in patients with NVAF was 1.4%. Ninety patients with atrial thrombus (mean age 62.8 ± 11.9 years and 61.1% men) were finally analyzed. Atrial thrombus was in the LAA in 82 (91.1%) patients. During follow up, 60% of the patients showed complete resolution of atrial thrombus. Congestive heart failure (odds ratio [OR]: 8.94; 95% confidence interval [CI]: 1.67-47.80) and a history of ischemic stroke (OR: 8.28; 95% CI: 1.48-46.42) were independently associated with the risk of the nonresolution of atrial thrombus. The presence of atrial thrombus in patients with NVAF who received anticoagulation therapy is non-negligible. Even in anticoagulated patients, TEE or cardiac CTA might still be needed. Congestive heart failure and a history of ischemic stroke are risk factors of the nonresolution of atrial thrombus.
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Affiliation(s)
- Shu Yang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yanjuan Zhang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ning Chen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jiaojiao Shi
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Weizhu Ju
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hongwu Chen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Gang Yang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zidun Wang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hailei Liu
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiaohong Jiang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Chang Cui
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Minglong Chen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Mingfang Li
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Heo J, Lee H, Lee IH, Nam HS, Kim YD. Impact of Left Atrial or Left Atrial Appendage Thrombus on Stroke Outcome: A Matched Control Analysis. J Stroke 2023; 25:111-118. [PMID: 36592972 PMCID: PMC9911853 DOI: 10.5853/jos.2022.02068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/30/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND AND PURPOSE Left atrial or left atrial appendage (LA/LAA) thrombi are frequently observed during cardioembolic evaluation in patients with ischemic stroke. This study aimed to investigate stroke outcomes in patients with LA/LAA thrombus. METHODS This retrospective study included patients admitted to a single tertiary center in Korea between January 2012 and December 2020. Patients with nonvalvular atrial fibrillation who underwent transesophageal echocardiography or multi-detector coronary computed tomography were included in the study. Poor outcome was defined as modified Rankin Scale score >3 at 90 days. The inverse probability of treatment weighting analysis was performed. RESULTS Of the 631 patients included in this study, 68 (10.7%) had LA/LAA thrombi. Patients were likely to have a poor outcome when an LA/LAA thrombus was detected (42.6% vs. 17.4%, P<0.001). Inverse probability of treatment weighting analysis yielded a higher probability of poor outcomes in patients with LA/LAA thrombus than in those without LA/LAA thrombus (P<0.001). Patients with LA/LAA thrombus were more likely to have relevant arterial occlusion on angiography (36.3% vs. 22.4%, P=0.047) and a longer hospital stay (8 vs. 7 days, P<0.001) than those without LA/LAA thrombus. However, there was no difference in early neurological deterioration during hospitalization or major adverse cardiovascular events within 3 months between the two groups. CONCLUSIONS Patients with ischemic stroke who had an LA/LAA thrombus were at risk of a worse functional outcome after 3 months, which was associated with relevant arterial occlusion and prolonged hospital stay.
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Affiliation(s)
- JoonNyung Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyungwoo Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Il Hyung Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea,Correspondence: Young Dae Kim Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: +82-2-2228-1619 Fax: +82-2-393-0705 E-mail:
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9
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Uziȩbło-Życzkowska B, Kapłon-Cieślicka A, Gawałko M, Budnik M, Starzyk K, Wożakowska-Kapłon B, Daniłowicz-Szymanowicz L, Kaufmann D, Wójcik M, Błaszczyk R, Hiczkiewicz J, Łojewska K, Mizia-Stec K, Wybraniec M, Kosmalska K, Fijałkowski M, Szymańska A, Gos A, Haberka M, Kucio M, Michalski B, Kupczyńska K, Tomaszuk-Kazberuk A, Wilk-Śledziewska K, Wachnicka-Truty R, Koziński M, Burchardt P, Krzesiński P. Risk factors for left atrial thrombus in younger patients (aged < 65 years) with atrial fibrillation or atrial flutter: Data from the multicenter left atrial thrombus on transesophageal echocardiography (LATTEE) registry. Front Cardiovasc Med 2022; 9:973043. [PMID: 36312270 PMCID: PMC9611536 DOI: 10.3389/fcvm.2022.973043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 09/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Methods Results Conclusions
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Affiliation(s)
- Beata Uziȩbło-Życzkowska
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland,*Correspondence: Beata Uziȩbło-Życzkowska
| | - Agnieszka Kapłon-Cieślicka
- “Club 30”, Polish Cardiac Society, Katowice, Poland,1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Monika Gawałko
- “Club 30”, Polish Cardiac Society, Katowice, Poland,1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland,West German Heart and Vascular Centre, Institute of Pharmacology, University Duisburg-Essen, Duisburg, Germany,Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Monika Budnik
- “Club 30”, Polish Cardiac Society, Katowice, Poland,1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | | | | | | | - Damian Kaufmann
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, Gdańsk, Poland
| | - Maciej Wójcik
- “Club 30”, Polish Cardiac Society, Katowice, Poland,Department of Cardiology, Medical University of Lublin, Lublin, Poland
| | - Robert Błaszczyk
- Department of Cardiology, Medical University of Lublin, Lublin, Poland
| | - Jarosław Hiczkiewicz
- Collegium Medicum, University of Zielona Góra, Zielona Góra, Poland,Clinical Department of Cardiology, Nowa Sól Multidisciplinary Hospital, Nowa Sol, Poland
| | - Katarzyna Łojewska
- Clinical Department of Cardiology, Nowa Sól Multidisciplinary Hospital, Nowa Sol, Poland
| | - Katarzyna Mizia-Stec
- “Club 30”, Polish Cardiac Society, Katowice, Poland,Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland,Members of the European Reference Network on Heart Diseases–ERN GUARD-HEART, Amsterdam, Netherlands
| | - Maciej Wybraniec
- “Club 30”, Polish Cardiac Society, Katowice, Poland,Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland,Members of the European Reference Network on Heart Diseases–ERN GUARD-HEART, Amsterdam, Netherlands
| | | | - Marcin Fijałkowski
- 1st Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Anna Szymańska
- Department of Heart Diseases, Postgraduate Medical School, Warsaw, Poland
| | - Aleksandra Gos
- Department of Heart Diseases, Postgraduate Medical School, Warsaw, Poland
| | - Maciej Haberka
- “Club 30”, Polish Cardiac Society, Katowice, Poland,Department of Cardiology, School of Health Sciences, Medical University of Silesia, Katowice, Poland
| | - Michał Kucio
- Department of Cardiology, School of Health Sciences, Medical University of Silesia, Katowice, Poland
| | - Błazej Michalski
- “Club 30”, Polish Cardiac Society, Katowice, Poland,Department of Cardiology, Medical University of Lodz, Lodz, Poland
| | - Karolina Kupczyńska
- “Club 30”, Polish Cardiac Society, Katowice, Poland,Department of Cardiology, Medical University of Lodz, Lodz, Poland
| | | | | | - Renata Wachnicka-Truty
- Department of Cardiology and Internal Medicine, Medical University of Gdańsk, Gdynia, Poland
| | - Marek Koziński
- “Club 30”, Polish Cardiac Society, Katowice, Poland,Department of Cardiology and Internal Medicine, Medical University of Gdańsk, Gdynia, Poland
| | - Paweł Burchardt
- “Club 30”, Polish Cardiac Society, Katowice, Poland,Department of Hypertension, Angiology, and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Paweł Krzesiński
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland,“Club 30”, Polish Cardiac Society, Katowice, Poland
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10
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Li M, Ning Y, Tse G, Saguner AM, Wei M, Day JD, Luo G, Li G. Atrial cardiomyopathy: from cell to bedside. ESC Heart Fail 2022; 9:3768-3784. [PMID: 35920287 PMCID: PMC9773734 DOI: 10.1002/ehf2.14089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/09/2022] [Accepted: 07/10/2022] [Indexed: 01/19/2023] Open
Abstract
Atrial cardiomyopathy refers to structural and electrical remodelling of the atria, which can lead to impaired mechanical function. While historical studies have implicated atrial fibrillation as the leading cause of cardioembolic stroke, atrial cardiomyopathy may be an important, underestimated contributor. To date, the relationship between atrial cardiomyopathy, atrial fibrillation, and cardioembolic stroke remains obscure. This review summarizes the pathogenesis of atrial cardiomyopathy, with a special focus on neurohormonal and inflammatory mechanisms, as well as the role of adipose tissue, especially epicardial fat in atrial remodelling. It reviews the current evidence implicating atrial cardiomyopathy as a cause of embolic stroke, with atrial fibrillation as a lagging marker of an increased thrombogenic atrial substrate. Finally, it discusses the potential of antithrombotic therapy in embolic stroke with undetermined source and appraises the available diagnostic techniques for atrial cardiomyopathy, including imaging techniques such as echocardiography, computed tomography, and magnetic resonance imaging as well as electroanatomic mapping, electrocardiogram, biomarkers, and genetic testing. More prospective studies are needed to define the relationship between atrial cardiomyopathy, atrial fibrillation, and embolic stroke and to establish a prompt diagnosis and specific treatment strategies in these patients with atrial cardiomyopathy for the secondary and even primary prevention of embolic stroke.
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Affiliation(s)
- Mengmeng Li
- Stroke Centre and Department of NeurologyThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Yuye Ning
- Stroke Centre and Department of NeurologyThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina,Department of NeurologyShaanxi People's HospitalXi'anChina
| | - Gary Tse
- Kent and Medway Medical SchoolCanterburyUK,Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
| | - Ardan M. Saguner
- Arrhythmia Division, Department of Cardiology, University Heart CentreUniversity Hospital ZurichZurichSwitzerland
| | - Meng Wei
- Stroke Centre and Department of NeurologyThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - John D. Day
- Department of CardiologySt. Mark's HospitalSalt Lake CityUTUSA
| | - Guogang Luo
- Stroke Centre and Department of NeurologyThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Guoliang Li
- Department of Cardiovascular MedicineThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
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11
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External validation and comparison of CHA 2DS 2-VASc-RAF and CHA 2DS 2-VASc-LAF scores for predicting left atrial thrombus and spontaneous echo contrast in patients with non-valvular atrial fibrillation. J Interv Card Electrophysiol 2022; 65:535-542. [PMID: 35831771 DOI: 10.1007/s10840-022-01285-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/17/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE CHA2DS2-VASc-RAF (R is renal dysfunction, and AF is atrial fibrillation type) and CHA2DS2-VASc-LAF (L is left atrial diameter, and AF is atrial fibrillation type) scores have been developed to estimate the risk of left atrial thrombus (LAT) and spontaneous echo contrast (SEC) in patients with non-valvular atrial fibrillation (NVAF). However, few external validations have been conducted to assess their accuracy. Thus, this study aimed to validate and compare the two modified scores for predicting LAT/SEC in patients with NVAF. METHODS This study included 399 patients with NVAF who underwent transesophageal echocardiography. Risk factors related to LAT/SEC were identified through logistic regression analysis, and predictive value and diagnostic efficiency were evaluated using receiver operating characteristic (ROC) curve. RESULTS Approximately 9.8% (39/399) of the patients with NVAF had LAT/SEC. Multivariate logistic regression analysis showed that history of stroke/transient ischemic attack, congestive heart failure, non-paroxysmal atrial fibrillation, lack of anticoagulation therapy, enlarged left atrial diameter, enlarged left ventricular end diastolic diameter, decreased left ventricular ejection fraction, decreased left atrial appendage emptying velocity, and decreased estimated glomerular filtration rate were independent risk factors for LAT/SEC. The CHA2DS2-VASc-LAF (area under the ROC curve [AUC] = 0.839) and CHA2DS2-VASc-RAF (AUC = 0.829) scores showed larger predictive values than the CHA2DS2-VASc (AUC = 0.737) and CHADS2 (AUC = 0.736) scores. The AUC of the CHA2DS2-VASc-RAF score was similar to that of the CHA2DS2-VASc-LAF score (Z = 0.432; P = 0.666). CONCLUSION This study validated that the CHA2DS2-VASc-RAF and CHA2DS2-VASc-LAF scores are useful prognostic scoring systems for predicting LAT/SEC in patients with NVAF.
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12
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Alsagaff MY, Susilo H, Pramudia C, Juzar DA, Amadis MR, Julario R, Raharjo SB, Dharmadjati BB, Lusida TTE, Azmi Y, Doevendans PAFM. Rapid Atrial Fibrillation in the Emergency Department. Heart Int 2022; 16:12-19. [PMID: 36275348 PMCID: PMC9524843 DOI: 10.17925/hi.2022.16.1.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 06/13/2022] [Indexed: 01/13/2024] Open
Abstract
Atrial fibrillation (AF) is the most common rhythm disorder seen in doctors' offices and emergency departments (EDs). In both settings, an AF holistic pathway including anticoagulation or stroke avoidance, better symptom management, and cardiovascular and comorbidity optimization should be followed. However, other considerations need to be assessed in the ED, such as haemodynamic instability, the onset of AF, the presence of acute heart failure and pre-excitation. Although the Advanced Cardiovascular Life Support guidelines (European Society of Cardiology guidelines, Acute Cardiac Care Association/European Heart Rhythm Association position statements) and several recent AF publications have greatly assisted physicians in treating AF with rapid ventricular response in the ED, further practical clinical guidance is required to improve physicians' skill and knowledge in providing the best treatment for patients. Herein, we combine multiple strategies with supporting evidence-based treatment and experiences encountered in clinical practice into practical stepwise approaches. We hope that the stepwise algorithm may assist residents and physicians in managing AF in the ED.
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Affiliation(s)
- Mochamad Yusuf Alsagaff
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University, Dr Soetomo General Hospital, Surabaya, Indonesia
| | - Hendri Susilo
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University, Dr Soetomo General Hospital, Surabaya, Indonesia
| | - Christian Pramudia
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University, Dr Soetomo General Hospital, Surabaya, Indonesia
| | - Dafsah Arifa Juzar
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Muhammad Rafdi Amadis
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University, Dr Soetomo General Hospital, Surabaya, Indonesia
| | - Rerdin Julario
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University, Dr Soetomo General Hospital, Surabaya, Indonesia
| | - Sunu Budhi Raharjo
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Budi Baktijasa Dharmadjati
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University, Dr Soetomo General Hospital, Surabaya, Indonesia
| | - Terrence Timothy Evan Lusida
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University, Dr Soetomo General Hospital, Surabaya, Indonesia
| | - Yusuf Azmi
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University, Dr Soetomo General Hospital, Surabaya, Indonesia
| | - Pieter AFM Doevendans
- Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, Netherlands
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13
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Shi S, Zhao Q, Liu T, Zhang S, Liang J, Tang Y, Yang B, Huang H, Huang C. Left Atrial Thrombus in Patients With Non-valvular Atrial Fibrillation: A Cross-Sectional Study in China. Front Cardiovasc Med 2022; 9:827101. [PMID: 35586655 PMCID: PMC9109812 DOI: 10.3389/fcvm.2022.827101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/14/2022] [Indexed: 12/05/2022] Open
Abstract
Background Stroke is predominately attributed to left atrial thrombus (LAT) in patients with non-valvular atrial fibrillation (NVAF), however, its detection rate in real clinical practice has been few reported in China. Objective This study aimed to investigate the prevalence and associated factors of LAT in patients with NVAF in China. Methods All adult NVAF patients undergoing transesophageal echocardiography (TEE) in the China Atrial Fibrillation Center database from January 2017 to January 2022 were enrolled in this study. The prevalence of LAT was calculated, and associated factors were identified. Results A total of 36,007 NVAF inpatients from 602 hospitals in 30 provinces/autonomous regions/municipalities were included in the final analysis, with a median age of 66 years and 39.4% were female. LAT was present in 1,467 (4.1%) patients overall, 2.7, 5.7, and 6.8% in patients with paroxysmal, persistent, and long-standing persistent AF, respectively. In subgroup analysis, including age ≥ 65 years, CHA2DS2-VASC score ≥ 2, left atrial diameter (LAD) ≥ 50 mm, left ventricular ejection fraction (LVEF) < 50%, and anticoagulation, patients with paroxysmal AF always had the lowest LAT prevalence, followed by patients with persistent and long-standing persistent AF. Patients treated with anticoagulants had less prevalent LAT than those without anticoagulation (2.1 vs. 5.0%, p < 0.001). In multivariate analysis, AF pattern (both persistent AF and long-standing persistent AF), hypertension, chronic heart failure, coronary heart disease, transient ischemic attack/stroke, diabetes mellitus, and LAD (per 5 mm) were associated with an increased prevalence of LAT. However, LVEF (per 5%) and anticoagulation were associated with a reduced prevalence of LAT. Conclusion LAT was found in 4.1% of Chinese adult NVAF inpatients underwent TEE in real-world experience. The prevalence of LAT mainly associated with non-paroxysmal AF, cardiovascular diseases, diabetes mellitus, enlarged left atrium, lower LVEF, and lack of anticoagulation therapy.
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Affiliation(s)
- Shaobo Shi
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan University, Wuhan, China
| | - Qingyan Zhao
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan University, Wuhan, China
| | - Tao Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan University, Wuhan, China
| | - Shujuan Zhang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan University, Wuhan, China
| | - Jinjun Liang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan University, Wuhan, China
| | - Yanhong Tang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan University, Wuhan, China
| | - Bo Yang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan University, Wuhan, China
| | - He Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan University, Wuhan, China
| | - Congxin Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan University, Wuhan, China
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14
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Dong SJ, Luo CY, Xiao CL, Zhang FZ, Li L, Han ZL, Zhai SD. Efficacy and Safety Profile of Novel Oral Anticoagulants in the Treatment of Left Atrial Thrombosis: A Systematic Review and Meta-Analysis. Curr Ther Res Clin Exp 2022; 96:100670. [PMID: 35515958 PMCID: PMC9062445 DOI: 10.1016/j.curtheres.2022.100670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 03/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background The presence of left atrial/left atrial appendage thrombosis is associated with a higher risk of thromboembolic events in patients with atrial fibrillation. The optimal antithrombotic strategy is not established to date. Objective Our aim was to compare the efficacy and safety profile of novel oral anticoagulants with warfarin in the treatment of left atrial/left atrial appendage thrombosis. Methods We conducted a systematic search in PubMed, Embase, Cochrane Library, ClinicalTrials.gov, and 3 Chinese databases for all randomized controlled trials and cohort studies (PROSPERO, CRD42021238952) from inception to 7 May 2021. Two authors independently performed the articles selection, data extraction, and quality assessment. The efficacy outcome was the resolution of left atrial/left atrial appendage thrombosis, and the safety outcomes were bleeding and stroke/transient ischemic attack. Results One randomized controlled trial and 5 cohort studies were included, with a total of 353 patients. Compared with warfarin, novel oral anticoagulants were associated with increased probability of left atrial/left atrial appendage thrombosis resolution (OR = 2.20; 95% CI, 1.35–3.60; I2 = 0%). Compared with warfarin, novel oral anticoagulants had a similar risk of bleeding (OR = 0.91; 95% CI, 0.39–2.13; I2 = 0%). There was no evidence of increased risk of stroke/transient ischemic attack (OR = 0.42; 95% CI, 0.12–1.45; I2 = 0%). Conclusions Novel oral anticoagulants were more effective than warfarin in promoting the resolution of left atrial/left atrial appendage thrombosis, without increased risks of bleeding and stroke/transient ischemic attack. Our study provides valuable insight into clinical practice. Further well-designed randomized controlled trials are needed to fully evaluate the benefits and risks in these patients. PROSPERO Registration No.: CRD42021238952.
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Affiliation(s)
- Shu-Jie Dong
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Cong-Yan Luo
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Department of Pharmacy, Karamay Second People's Hospital, Karamay, China
| | - Cui-Lan Xiao
- Department of Pharmacy, Karamay Second People's Hospital, Karamay, China
| | - Feng-Zhe Zhang
- School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Lei Li
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
| | - Zhong-Ling Han
- Department of Pharmacy, Beijing Road Medical Area of Xinjiang Military Region General Hospital, Urumqi, China
| | - Suo-Di Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Address correspondence to: Suo-Di Zhai, BSc, Department of Pharmacy, Peking University Third Hospital, No. 49 N Garden Rd, Haidian District, Beijing, China.
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15
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Cao M, Guo H, Zhao X, Li X, Sun C. Refinement of CHADS2 and CHA2DS2-VASc scores predict left atrial thrombus or spontaneous echo contrast in nonvalvular atrial fibrillation patients. J Int Med Res 2022; 50:3000605221074520. [PMID: 35196885 PMCID: PMC8883313 DOI: 10.1177/03000605221074520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective To investigate the risk factors of left atrial thrombus (LAT)/spontaneous echo contrast (SEC) in patients with nonvalvular atrial fibrillation (AF). Methods This retrospective study analysed the data from consecutive patients with nonvalvular AF that underwent transoesophageal echocardiography. Logistic regression analysis was performed to identify risk factors of LAT/SEC. Receiver operating characteristic curve analysis was undertaken compare the new scales with CHADS2 and CHA2DS2-VASc scores. Results A total of 558 patients with AF were included in the study. LAT/SEC was detected in 137 (24.6%) patients. The independent risk factors of LAT/SEC beyond CHADS2 or CHA2DS2-VASc scores included non-paroxysmal AF and left atrial diameter >37.5 mm. These two variables were added into the CHADS2 or CHA2DS2-VASc score to build new scales. Areas under the curve for the new scales based on CHADS2 and CHA2DS2-VASc scores were significantly higher than the CHADS2 or CHA2DS2-VASc score both in the overall study cohort and in patients at a high risk of thromboembolism. Conclusions Non-paroxysmal AF and increased left atrial diameter beyond the CHADS2 or CHA2DS2-VASc score were independent risk factors of LAT/SEC and may help to improve the current risk stratification, especially for patients with nonvalvular AF at a high risk of thromboembolism.
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Affiliation(s)
- Miaomiao Cao
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Huihui Guo
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Xiao Zhao
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Xiyang Li
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Chaofeng Sun
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
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16
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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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17
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Diagnostic accuracy of D-dimer to detect left atrial thrombus in patients with atrial fibrillation: A systematic review and meta-analysis. Heart Rhythm 2021; 18:2128-2136. [PMID: 34481076 DOI: 10.1016/j.hrthm.2021.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND There is conflicting evidence about the use of biomarkers to diagnose left atrial thrombus in patients with atrial fibrillation. OBJECTIVE The purpose of this study was to assess the diagnostic accuracy of D-dimer to detect left atrial thrombus in patients with atrial fibrillation. METHODS We searched 4 electronic databases from inception to December 16, 2020. The reference standard was left atrial thrombus detected by transesophageal echocardiography. Study quality was assessed with the Quality Assessment of Diagnostic Accuracy Studies 2 tool. We used a bivariate model to calculate the pooled sensitivity and specificity with their 95% confidence intervals (CIs). The optimal cutoff and predictive values were also estimated. RESULTS Eleven cross-sectional studies involving 4380 patients were included. The median prevalence of left atrial thrombus was 12%. In 7 studies, the pooled sensitivity of D-dimer at 500 ng/mL was 50% (95% CI 26%-74%) and the pooled specificity was 88% (95% CI 76%-95%). The pooled sensitivity of age-adjusted D-dimer was 36% (95% CI 14%-66%) and the pooled specificity was 99% (95% CI 96%-99%) in 2 studies. The optimal cutoff of D-dimer was 390 ng/mL in 10 studies with a pooled sensitivity of 68% (95% CI 44%-85%) and a pooled specificity of 73% (95% CI 54%-86%). The positive and negative predictive values were 21.8% and 95.4%, respectively. The risk of bias was low or unclear for all domains. Concerns about applicability were low for almost all studies. CONCLUSION Our meta-analysis suggests that D-dimer has the potential to be useful to rule out left atrial thrombus in patients with atrial fibrillation.
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18
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Backhaus JF, Pflaumbaum A, Krogias C, Kreimer F, Mügge A, Gold R, Gotzmann M. Short- and long-term outcome of patients with spontaneous echo contrast or thrombus in the left atrial appendage in the era of the direct acting anticoagulants. Clin Res Cardiol 2021; 110:1811-1821. [PMID: 34436659 PMCID: PMC8563546 DOI: 10.1007/s00392-021-01926-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/16/2021] [Indexed: 12/21/2022]
Abstract
Background Thrombi and spontaneous echo contrast (SEC) in the left atrial appendage (LAA) are associated with thromboembolic events and poor prognosis. There are very few data on long-term outcome, especially with the use of direct acting anticoagulants (DOAC). Methods In this retrospective study, all transoesophageal echocardiographies performed at a tertiary care university hospital from 2015 to 2020 were analyzed. All patients with thrombus or SEC in the LAA were included. Medical history, laboratory, echocardiographic parameters and medication at discharge were documented. The primary endpoint of the study was a composite endpoint (all-cause mortality, non-fatal stroke or transient ischaemic attack [TIA], non-fatal systemic embolization, non-fatal major bleeding and non-fatal myocardial infarction). Results Of a total of 4062 transoesophageal echocardiographies, thrombi were detected in 51 patients (1.2%) and SEC in 251 patients (6.2%). These patients formed the final study cohort (n = 302). During a mean follow-up period of 956 ± 663 days, 87 patients (29%) suffered the primary point. The following baseline characteristics predicted the primary endpoint: age, haemoglobin, a previous coronary artery bypass grafting, dialysis and choice of anticoagulation. Prescription of apixaban at discharge was associated with lower rate of adverse events (hazard ratio 0.564, confidence interval 0.331–0.960; p = 0.035) while prescription of dabigatran was associated with higher rate of adverse events (hazard ratio 3.091, confidence interval 1.506–6.347; p = 0.002). Conclusion Even in the DOAC era, the occurrence of thrombus or SEC in the LAA is associated with a high rate of MACCE. Our study suggests that the choice of DOAC therapy may have an impact on long-term survival. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s00392-021-01926-8.
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Affiliation(s)
- Julian Felix Backhaus
- Cardiology and Rhythmology, University Hospital St. Josef Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Andreas Pflaumbaum
- Cardiology and Rhythmology, University Hospital St. Josef Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Christos Krogias
- Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Fabienne Kreimer
- Cardiology and Rhythmology, University Hospital St. Josef Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Andreas Mügge
- Cardiology and Rhythmology, University Hospital St. Josef Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Ralf Gold
- Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Michael Gotzmann
- Cardiology and Rhythmology, University Hospital St. Josef Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany.
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Farkowski MM, Jubele K, Marín F, Gandjbakhch E, Ptaszynski P, Merino JL, Lenarczyk R, Potpara TS. Diagnosis and management of left atrial appendage thrombus in patients with atrial fibrillation undergoing cardioversion or percutaneous left atrial procedures: results of the European Heart Rhythm Association survey. Europace 2021; 22:162-169. [PMID: 31501852 DOI: 10.1093/europace/euz257] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 08/19/2019] [Indexed: 12/24/2022] Open
Abstract
Practices regarding indications and timing for transoesophageal echocardiography (TOE) before cardioversion (CV) of atrial fibrillation (AF) or left atrial (LA) interventional procedures, and preferred imaging techniques and pharmacotherapy, in cases of thrombus resistant to chronic oral anticoagulation (OAC) treatment, are largely unknown. The European Heart Rhythm Association (EHRA) conducted a survey to capture contemporary clinical practice in those areas of AF care. A 22-item online questionnaire was developed and distributed among the EHRA electrophysiology research network centres. The survey contained questions regarding indications, type and timing of imaging before CV or LA procedures and management of LA appendage (LAA) thrombus with special emphasis on thrombus resistant to OAC. Of 54 responding centres 63% were university hospitals. Most commonly, TOE would be performed in cases of inadequate or unclear pre-procedural anticoagulation, even in AF lasting <48 h (52% and 50%, respectively), and 15% of centres would perform TOE before AF ablation in all patients. If thrombus was diagnosed despite chronic OAC, the prevalent strategy was to change current OAC to another with different mechanism of action; 51% of centres would wait 3-4 weeks after changing the OAC before using another imaging test, and 60% of centres reported two attempts to dissolve the thrombus. Our survey showed a significant utilization of TOE before CV or AF ablation in European centres, extending beyond AF guidelines-suggested indications. When thrombus was diagnosed despite chronic pre-procedural OAC, most centres would use another anticoagulant drug with different mode of action.
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Affiliation(s)
- Michal M Farkowski
- Heart Arrhythmia Ward, II Department of Coronary Artery Disease, Institute of Cardiology, Alpejska 42, Warsaw, Poland
| | - Kristine Jubele
- P. Stradins Clinical University Hospital, Riga Stradins University, Riga, Latvia
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, CIBERCV, University of Murcia, Murcia, Spain
| | - Estelle Gandjbakhch
- Sorbonne Universités, APHP, Institute of Cardiology ICAN, Pitié-Salpêtrière University Hospital, Paris, France
| | - Pawel Ptaszynski
- Department of Electrocardiology, Medical University of Lodz, Lodz, Poland
| | - Jose L Merino
- Unidad de Arritmias y Electrofisiología Robotizada, La Paz University Hospital, IDIPAZ, Universidad Autonoma de Madrid, Madrid, Spain
| | - Radoslaw Lenarczyk
- First Department of Cardiology and Angiology, Silesian Centre for Heart Disease, Zabrze, Poland
| | - Tatjana S Potpara
- School of Medicine, Belgrade University; Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
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Brandes A, Crijns HJGM, Rienstra M, Kirchhof P, Grove EL, Pedersen KB, Van Gelder IC. Cardioversion of atrial fibrillation and atrial flutter revisited: current evidence and practical guidance for a common procedure. Europace 2021; 22:1149-1161. [PMID: 32337542 PMCID: PMC7399700 DOI: 10.1093/europace/euaa057] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/25/2020] [Indexed: 12/17/2022] Open
Abstract
Cardioversion is widely used in patients with atrial fibrillation (AF) and atrial flutter when a rhythm control strategy is pursued. We sought to summarize the current evidence on this important area of clinical management of patients with AF including electrical and pharmacological cardioversion, peri-procedural anticoagulation and thromboembolic complications, success rate, and risk factors for recurrence to give practical guidance.
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Affiliation(s)
- Axel Brandes
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Corresponding author. Tel: +45 30 43 36 50. E-mail address:
| | - Harry J G M Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Centre, Groningen, The Netherlands
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, UHB and Sandwell & West Birmingham Hospitals, NHS Trusts, Birmingham, UK
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Kenneth Bruun Pedersen
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark
| | - Isabelle C Van Gelder
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, University of Groningen, University Medical Centre, Groningen, The Netherlands
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21
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Baumeister TB, Helfen A, Wickenbrock I, Perings C. Vorhofflimmern und NOAK-Therapie: Benötigen wir eine transösophageale Echokardiografie vor Kardioversion? AKTUELLE KARDIOLOGIE 2021. [DOI: 10.1055/a-1470-2151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungVorhofflimmern ist ein häufiger Grund für einen Schlaganfall. Insbesondere Patienten ohne
adäquate Antikoagulation haben ein erhöhtes Risiko für thromboembolische Ereignisse (ca.
5–7%). Es liegt eine Assoziation zwischen Kardioversionen und embolischen Ereignissen vor.
Durch eine orale Antikoagulation (OAK) mit Nicht-Vitamin-K-Antagonisten (NOAK) kann dieses
Risiko auf unter 1% reduziert werden. Es gibt 2 unterschiedliche Kardioversionsstrategien. Zum
einen kann eine Kardioversion nach 3-wöchiger effektiver Antikoagulation ohne weitere
Bildgebung durchgeführt werden. Zum anderen kann nach Ausschluss einer intrakardialen
Thrombenbildung durch eine TEE umgehend sicher kardiovertiert werden. Bei Vorhofflimmern
sollte nach der Kardioversion eine effektive Antikoagulation für mindestens 4 Wochen erfolgen,
unabhängig vom CHA2DS2-VASc-Score. Eine Bildgebung mittels TEE ist
notwendig, wenn die Dauer einer effektiven Antikoagulation <3 Wochen ist, Unsicherheiten
bezüglich der regelmäßigen und lückenlosen Medikamenteneinnahme bestehen oder ein hohes Risiko
für linksatriale Thromben besteht.
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Affiliation(s)
- Timo-Benjamin Baumeister
- Klinik für Kardiologie, Elektrophysiologie, Pneumologie und internistische Intensivmedizin, Katholisches Klinikum Lünen Werne GmbH, St. Marien-Hospital Lünen, Lünen, Deutschland
| | - Andreas Helfen
- Klinik für Kardiologie, Elektrophysiologie, Pneumologie und internistische Intensivmedizin, Katholisches Klinikum Lünen Werne GmbH, St. Marien-Hospital Lünen, Lünen, Deutschland
| | - Ingo Wickenbrock
- Klinik für Kardiologie, Elektrophysiologie, Pneumologie und internistische Intensivmedizin, Katholisches Klinikum Lünen Werne GmbH, St. Marien-Hospital Lünen, Lünen, Deutschland
| | - Christian Perings
- Klinik für Kardiologie, Elektrophysiologie, Pneumologie und internistische Intensivmedizin, Katholisches Klinikum Lünen Werne GmbH, St. Marien-Hospital Lünen, Lünen, Deutschland
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22
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Lurie A, Wang J, Hinnegan KJ, McIntyre WF, Belley-Côté EP, Amit G, Healey JS, Connolly SJ, Wong JA. Prevalence of Left Atrial Thrombus in Anticoagulated Patients With Atrial Fibrillation. J Am Coll Cardiol 2021; 77:2875-2886. [PMID: 34112315 DOI: 10.1016/j.jacc.2021.04.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The prevalence of left atrial (LA) thrombus in patients with atrial fibrillation (AF) or atrial flutter (AFL) on guideline-directed anticoagulation is not well known, yet this may inform transesophageal echocardiogram (TEE) use before cardioversion or catheter ablation. OBJECTIVES The purpose of this study was to quantify LA thrombus prevalence among patients with AF/AFL on guideline-directed anticoagulation and to identify high-risk subgroups. METHODS EMBASE, MEDLINE, and CENTRAL were systematically searched from inception to July 2020 for studies reporting on LA thrombus prevalence among patients with AF/AFL undergoing TEE following at least 3 weeks of continuous therapeutic oral anticoagulation with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). Meta-analysis was performed using random effects models. RESULTS Thirty-five studies describing 14,653 patients were identified. The mean-weighted LA thrombus prevalence was 2.73% (95% confidence interval [CI]: 1.95% to 3.80%). LA thrombus prevalence was similar for VKA- and DOAC-treated patients (2.80%; 95% CI: 1.86% to 4.21% vs. 3.12%; 95% CI: 1.92% to 5.03%; p = 0.674). Patients with nonparoxysmal AF/AFL had a 4-fold higher LA thrombus prevalence compared with paroxysmal patients (4.81%; 95% CI: 3.35% to 6.86% vs. 1.03%; 95% CI: 0.52% to 2.03%; p < 0.001). LA thrombus prevalence was higher among patients undergoing cardioversion versus ablation (5.55%; 95% CI: 3.15% to 9.58% vs. 1.65%; 95% CI: 1.07% to 2.53%; p < 0.001). Patients with CHA2DS2-VASc scores ≥3 had a higher LA thrombus prevalence compared with patients with scores ≤2 (6.31%; 95% CI: 3.72% to 10.49% vs. 1.06%; 95% CI: 0.45% to 2.49%; p < 0.001). CONCLUSIONS LA thrombus prevalence is high in subgroups of anticoagulated patients with AF/AFL, who may benefit from routine pre-procedural TEE use before cardioversion or catheter ablation.
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Affiliation(s)
- Antony Lurie
- Population Health Research Institute, Hamilton, Ontario, Canada; University of Western Ontario, London, Ontario, Canada
| | - Jia Wang
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada
| | | | - William F McIntyre
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada
| | - Emilie P Belley-Côté
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Guy Amit
- Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jorge A Wong
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
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23
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Are Three Weeks of Oral Anticoagulation Sufficient for Safe Cardioversion in Atrial Fibrillation? MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57060554. [PMID: 34072778 PMCID: PMC8229733 DOI: 10.3390/medicina57060554] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/18/2021] [Accepted: 05/28/2021] [Indexed: 11/24/2022]
Abstract
Background and Objectives: Patients with atrial fibrillation (AF), lasting >48 h, considered for cardioversion, are recommended ≥3 weeks of oral anticoagulation before sinus rhythm restoration because of high risk of development of left atrial thrombosis (LAT) and stroke. However, the optimal duration of anticoagulation in the presence of overt LAT is unknown. Materials and Methods: An open-label study aimed to investigate the prevalence of spontaneous echo contrast (SEC) and LAT before and after 3 weeks of direct oral anticoagulant (DOAC) treatment. We included 51 consecutive patients (50.9% males), mean age 69.3 ± 7.4 years with paroxysmal/unknown duration of AF, considered for cardioversion, who agreed to have transesophageal echocardiography at enrollment and 3 weeks later. Results: At baseline SEC was present in 26 (50.9%) and LAT in 10 (19.6%) of 51 patients. After 3 weeks on DOAC, SEC persisted in 12 (25.0%) and LAT in 7 (14.5%) of 48 patients, p < 0.05 vs. baseline. Factors, associated most strongly with persistence of SEC/LAT, were left atrial appendage (LAA) emptying velocity <20 cm/s (OR = 2.82), LAA lobes >2 (OR = 1.84), and indexed left atrial volume ≥34 mL/m2 (OR = 1.37). Conclusions: In our study the incidence of SEC/LAT, particularly in AF with unknown duration, was not as low as we expected. The prevalence of SEC/LAT seemed to be dependent on factors not routinely evaluated in AF patients planned for cardioversion (indexed LA volume, LAA morphology and number of lobules, LAA emptying velocity, etc.). Our data suggested an individualized approach for DOAC duration in AF patients before an attempt for restoration of sinus rhythm is made, taking into consideration the LAA morphology and function.
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24
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Van Laer SL, Verreyen S, Winkler KM, Miljoen H, Sarkozy A, Heuten H, Saenen J, Van Herck P, Van de Heyning CM, Heidbuchel H, Claeys MJ. Effect of Mitral Regurgitation on Thrombotic Risk in Patients With Nonrheumatic Atrial Fibrillation: A New CHA 2DS 2-VASc Score Risk Modifier? Am J Cardiol 2021; 145:69-76. [PMID: 33454347 DOI: 10.1016/j.amjcard.2021.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/30/2020] [Accepted: 01/05/2021] [Indexed: 11/26/2022]
Abstract
The current study assessed the effect of mitral regurgitation (MR) on thrombotic risk in nonrheumatic atrial fibrillation (AF). AF carries a thrombotic risk related to left atrial blood stasis. The prevalence of atrial thrombosis, defined as the presence of left atrial appendage thrombus and/or left atrial spontaneous echo contrast grade >2, was determined in 686 consecutive nonrheumatic AF patients without (adequate) anticoagulation scheduled for transesophageal echocardiography before electrical cardioversion and was related to the severity of MR adjusted for the CHA2DS2-VASc score. A total of 103 (15%) patients had severe MR, 210 (31%) had moderate MR, and 373 (54%) had no-mild MR; the median CHA2DS2-VASc score was 3.0 (interquartile range 2.0 to 4.0). Atrial thrombosis was observed in 118 patients (17%). The prevalence of atrial thrombosis decreased with increasing MR severity: 19.9% versus 15.2% versus 11.6% for no-mild, moderate, and severe MR, respectively (p value for trend = 0.03). Patients with moderate and severe MR had a lower risk of atrial thrombosis than patients with no-mild MR, with adjusted odds ratios of 0.51 (95% confidence interval 0.31 to 0.84) and 0.24 (95% confidence interval 0.11 to 0.49), respectively. The protective effect of MR was present across all levels of the CHA2DS2-VASc risk score and the presence of moderate-severe MR in patients with an intermediate CHA2DS2-VASc score (2 to 3) lowered the atrial thrombotic risk to the level of patients with a low CHA2DS2-VASc score (0 to 1). In conclusion, our data show that the presence of MR attenuated the atrial thrombotic risk by more than 50% in patients with nonrheumatic AF.
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25
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Zhang H, Yu M, Xia Y, Li X, Liu J, Fang P. The differences of atrial thrombus locations and variable response to anticoagulation in nonvalvular atrial fibrillation with ventricular cardiomyopathy. J Arrhythm 2020; 36:1016-1022. [PMID: 33335618 PMCID: PMC7733561 DOI: 10.1002/joa3.12422] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/03/2020] [Accepted: 08/06/2020] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES This study aims to research the clinical features of atrial thrombi in patients with nonvalvular atrial fibrillation (AF). METHODS This study included 191 patients of AF who had atrial thrombi. One hundred and twenty-eight of them were assigned into nonventricular cardiomyopathy group (non-VCM), and the remaining 63 into ventricular cardiomyopathy group (VCM). After atrial thrombi diagnosed, all patients had taken oral anticoagulant therapy. The resolution rates of thrombi within 12 months were compared between the two groups, as well as the locations of thrombi. RESULTS Of all 191 patients, 161 had thrombi only detected in left atrial appendage (LAA), 20 in both left atrium (LA) and LAA, six in LA only, and four in right atrium only. More patients had thrombi out of LAA in the VCM group than in the non-VCM group (30.2% vs 8.6%, P < .001). After propensity score matching, the atrial thrombi were resolved faster in the non-VCM group than in the VCM group (mean time length: 22 ± 2 weeks vs 30 ± 3 weeks, P = .038), and the resolution rate within 12 months was higher in the non-VCM group than in the VCM group (88.7% vs 61.4%, Log-rank, P = .038). In Cox proportional hazards model, absence of ventricular cardiomyopathy was an independent predictor for the resolution of atrial thrombus (hazard ratio: 1.76; P = .035). CONCLUSIONS The patients of atrial fibrillation with ventricular cardiomyopathies have higher incidence of thrombosis in the body of left atrium or right atrium. And the resolution rate was lower in these patients.
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Affiliation(s)
- Hao Zhang
- Chinese Academy of Medical Sciences and Peking Union Medical CollegeFuwai HospitalBeijingChina
- Department of CardiologyChongqing General HospitalUniversity of Chinese Academy of SciencesChongqingChina
| | - Miao Yu
- Chinese Academy of Medical Sciences and Peking Union Medical CollegeFuwai HospitalBeijingChina
| | - Yu Xia
- Chinese Academy of Medical Sciences and Peking Union Medical CollegeFuwai HospitalBeijingChina
| | - Xiaofeng Li
- Chinese Academy of Medical Sciences and Peking Union Medical CollegeFuwai HospitalBeijingChina
| | - Jun Liu
- Chinese Academy of Medical Sciences and Peking Union Medical CollegeFuwai HospitalBeijingChina
| | - Pihua Fang
- Chinese Academy of Medical Sciences and Peking Union Medical CollegeFuwai HospitalBeijingChina
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26
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Merino JL, Lip GYH, Heidbuchel H, Cohen AA, De Caterina R, de Groot JR, Ezekowitz MD, Le Heuzey JY, Themistoclakis S, Jin J, Melino M, Winters SM, Merkely B, Goette A. Determinants of left atrium thrombi in scheduled cardioversion: an ENSURE-AF study analysis. Europace 2020; 21:1633-1638. [PMID: 31436835 PMCID: PMC6826208 DOI: 10.1093/europace/euz213] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 08/07/2019] [Indexed: 12/17/2022] Open
Abstract
Aims ENSURE-AF (NCT 02072434) was the largest prospective randomized clinical trial of anticoagulation for cardioversion in atrial fibrillation (AF), which also provides the largest prospective dataset for transoesophageal echocardiography (TOE) prior to cardioversion. This ancillary analysis investigated determinants of TOE-detected left atrium thrombi (LAT) in patients scheduled for electrical cardioversion (ECV). Methods and results The ENSURE-AF multicentre PROBE evaluation trial compared edoxaban 60 mg once daily (QD) with enoxaparin/warfarin in 2199 subjects undergoing ECV of non-valvular AF. Patients were stratified by the use of TOE, anticoagulant experience, and selected edoxaban dose. Electrical cardioversion was cancelled or deferred when TOEdetected LAT. In total, 1183 subjects were stratified to the TOE arm and LAT was reported in 91 (8.2%). In univariate analysis, age ≥75 years (26.4% vs. 16.9%, P = 0.0308), lower weight (86.5 ± 15.0 vs. 90.7 ± 18.0 kg, P = 0.0309), lower creatinine clearance (80.1 ± 30.6 vs. 93.2 ± 33.9 mL/min, P = 0.0007), heart failure (59.3% vs. 43.0%, P = 0.0029), and diuretic treatment (53.9% vs. 40.1%, P = 0.0141) were more prevalent in the LAT group. Non-significant trends were seen for higher mean CHA2DS2-VASc score (3.0 ± 1.41 vs. 2.7 ± 1.48, P = 0.0571) and more prevalent anticoagulation use prior to enrolment (60.4% vs. 50.3%, P = 0.0795) in the LAT group. In logistic regression analysis, age (P = 0.0202) and heart failure (P = 0.0064) were independently associated with LAT. Conclusion Elective ECV is commonly cancelled or deferred due to TOE-detected LAT in patients with non-valvular AF. Age ≥75 years and heart failure were associated with the presence of LAT.
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Affiliation(s)
- Jose L Merino
- Arrhythmia and Robotic Electrophysiology Unit, Hospital Universitario La Paz, IDIPaz, Departamento de Medicina de la Universidad Autonoma de Madrid, P. Castellana, 261 (H. Gral, 1st Floor), Madrid, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Hein Heidbuchel
- Department of Cardiology, Antwerp University and University Hospital, Wijlrijkstraat 10, Antwerp, Edegem, Belgium
| | - Aron-Ariel Cohen
- Service de cardiologie, INSERM 856 and Hôpital Saint Antoine, Hôpital Tenon; Sorbonne-Université (Université Pierre et Marie Curie, Paris VI), 1 rue Victor Cousin, Paris, France
| | - Raffaele De Caterina
- Chair of Cardiology, University of Pisa and Cardiology Division, Pisa University Hospital, Pisa, Italy
| | - Joris R de Groot
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Heart Center, Meibergdreef 9, AZ, Amsterdam, The Netherlands
| | - Michael D Ezekowitz
- Department of Cardiovascular Medicine, Sidney Kimmel Jefferson Medical College at Thomas Jefferson University, 1025 Walnut St #100, Philadelphia, PA, USA; Lankenau Medical Center, 100 East Lancaster Avenue, Wynnewood, PA, USA and Bryn Mawr Hospital, 130 South Bryn Mawr Avenue Bryn Mawr, PA, USA
| | - Jean-Yves Le Heuzey
- Cardiology and Arrhythmology, Georges Pompidou Hospital, René Descartes University, 20 Rue Leblanc, Paris, France
| | - Sakis Themistoclakis
- Unit of Electrophysiology and Cardiac Pacing, Dell'Angelo Hospital, Via Paccagnella, 11, Venice-Mestre, Italy
| | - James Jin
- Daiichi Sankyo Pharma Development, 211 Mt Airy Rd, Basking Ridge, NJ, USA
| | - Michael Melino
- Daiichi Sankyo Pharma Development, 211 Mt Airy Rd, Basking Ridge, NJ, USA
| | | | - Béla Merkely
- Semmelweis University Heart and Vascular Center, Városmajor u.68, Budapest, Hungary
| | - Andreas Goette
- St. Vincenz-Hospital, Paderborn, Am Busdorf 2, Paderborn, Nordrhein-Westfalen, Germany.,Working Group: Molecular Electrophysiology, University Hospital Magdeburg, Leipziger Str. 44, Magdeburg, Germany
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Left Atrial Appendage Thrombus Formation Despite Continuous Non-Vitamin K Antagonist Oral Anticoagulant Therapy in Atrial Fibrillation Patients Undergoing Electrical Cardioversion or Catheter Ablation: A Comparison of Dabigatran and Rivaroxaban. Cardiol Res Pract 2020; 2020:1206402. [PMID: 33014453 PMCID: PMC7519465 DOI: 10.1155/2020/1206402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/23/2020] [Accepted: 08/25/2020] [Indexed: 11/18/2022] Open
Abstract
Left atrial appendage thrombus (LAAT) may be detected by transesophageal echocardiography (TOE) in patients with atrial fibrillation (AF) despite continuous anticoagulation therapy. We examined the factors predisposing to LAAT in patients treated with the anticoagulants dabigatran and rivaroxaban. We retrospectively evaluated 1,256 AF patients from three centres who underwent TOE before electrical cardioversion (n = 611, 51.4%) or catheter ablation (n = 645, 48.6%) from January 2013 to December 2019 and had been on at least three weeks of continuous dabigatran (n = 603, 48%) or rivaroxaban (n = 653, 52%) therapy. Preprocedural TOE diagnosed LAAT in 51 patients (4.1%), including 30 patients (5%) treated with dabigatran and 21 patients (3.2%) treated with rivaroxaban (p=0.1145). In multivariate logistic regression, predictors of LAAT in patients treated with dabigatran were non-paroxysmal AF (vs. paroxysmal AF) (OR = 6.2, p=0.015), heart failure (OR = 3.22, p=0.003), and a eGFR <60 ml/min/1.73 m2 (OR = 2.65, p=0.012); the predictors in patients treated with rivaroxaban were non-paroxysmal AF (vs. paroxysmal AF) (OR = 5.73, p=0.0221) and heart failure (OR = 3.19, p=0.116). In ROC analysis of the dabigatran group, the area under the curve (AUC) for the CHA2DS2-VASc-RAF score was significantly higher (0.78) than those for the CHADS2, CHA2DS2-VASc, and R2CHADS2 scores (0.67, 0.70, and 0.72, respectively). In the rivaroxaban group, the CHA2DS2-VASc-RAF score also performed significantly better (AUC of 0.77) than the CHADS2, CHA2DS2-VASc, and R2CHADS2 scores (AUC of 0.66, 0.64, and 0.67, respectively). The risk of LAAT was the same for patients in both treatment groups. In all patients, non-paroxysmal AF or heart failure, and in patients treated with dabigatran an eGFR <60 ml/min/1.73 m2, were independent predictors of LAAT. The new CHA2DS2-VASc-RAF scale had the highest predictive value for LAAT in the entire study population.
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Stachel G, Woitek FJ, Crusius L, Haussig S, Kiefer P, Leontyev S, Schlotter F, Spindler A, Höllriegel R, Hommel J, Borger MA, Thiele H, Holzhey D, Linke A, Mangner N. Left-Atrial Appendage Thrombosis in Patients With Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation. Can J Cardiol 2020; 37:450-457. [PMID: 32450289 DOI: 10.1016/j.cjca.2020.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/25/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Data about the impact of left-atrial appendage thrombosis (LAAT) on early safety and mortality in patients undergoing transfemoral transcatheter aortic valve implantation (TF-TAVI) are scarce. We aimed to investigate the prevalence and predictors of LAAT and the outcome associated with this condition in patients treated by TF-TAVI. METHODS Retrospective data analysis was derived from a prospective single-centre registry comparing patients with and without LAAT regarding early safety at 30 days, according to Valve Academic Research Consortium-2 (VARC-2) and 2-year mortality. RESULTS LAAT was found in 7.6% of the whole cohort (n = 2527) and in 16.6% in those patients with known pre-existing atrial fibrillation (AF cohort, n = 1099). Compared with controls, patients with LAAT were sicker, indicated by a higher Society of Thoracic Surgeons (STS) score and burden of comorbidities. Neither VARC-2-defined early safety at 30 days nor the rate of stroke was different between LAAT and controls in both the whole (early safety: 29.2% vs 24.2%, P = 0.123; stroke: 5.9% vs 4.7%, P = 0.495) and AF cohort (early safety: 29.1% vs 22.9%, P = 0.072; stroke: 5.6% vs 3.3%, P = 0.142). Evaluating the whole cohort in a univariate analysis, the 2-year mortality was significantly higher in LAAT compared with controls (hazard ratio, 1.41; 95% confidence interval, 1.07-1.86; P = 0.014). However, multivariate analysis of the whole cohort and the AF cohort revealed no association between LAAT and 2-year mortality. CONCLUSIONS LAAT was frequent in patients undergoing TF-TAVI- in particular, in patients with histories of AF-but it was not associated with an increase in periprocedural complications and did not predict 2-year mortality.
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Affiliation(s)
- Georg Stachel
- Heart Center Leipzig at the University of Leipzig, Department of Cardiology, Leipzig, Germany
| | - Felix J Woitek
- Herzzentrum Dresden, Technische Universität Dresden, Department of Internal Medicine and Cardiology, Dresden, Germany
| | - Lisa Crusius
- Heart Center Leipzig at the University of Leipzig, Department of Cardiology, Leipzig, Germany
| | - Stephan Haussig
- Herzzentrum Dresden, Technische Universität Dresden, Department of Internal Medicine and Cardiology, Dresden, Germany
| | - Philipp Kiefer
- Heart Center Leipzig-University Hospital, Department of Cardiac Surgery, Leipzig, Germany
| | - Sergey Leontyev
- Heart Center Leipzig-University Hospital, Department of Cardiac Surgery, Leipzig, Germany
| | - Florian Schlotter
- Heart Center Leipzig at the University of Leipzig, Department of Cardiology, Leipzig, Germany
| | - Aileen Spindler
- Heart Center Leipzig at the University of Leipzig, Department of Cardiology, Leipzig, Germany
| | - Robert Höllriegel
- Herzzentrum Dresden, Technische Universität Dresden, Department of Internal Medicine and Cardiology, Dresden, Germany
| | - Jennifer Hommel
- Herzzentrum Dresden, Technische Universität Dresden, Department of Internal Medicine and Cardiology, Dresden, Germany
| | - Michael A Borger
- Heart Center Leipzig-University Hospital, Department of Cardiac Surgery, Leipzig, Germany
| | - Holger Thiele
- Heart Center Leipzig at the University of Leipzig, Department of Cardiology, Leipzig, Germany
| | - David Holzhey
- Heart Center Leipzig-University Hospital, Department of Cardiac Surgery, Leipzig, Germany
| | - Axel Linke
- Herzzentrum Dresden, Technische Universität Dresden, Department of Internal Medicine and Cardiology, Dresden, Germany
| | - Norman Mangner
- Herzzentrum Dresden, Technische Universität Dresden, Department of Internal Medicine and Cardiology, Dresden, Germany.
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Kozieł M, Merino JL, De Caterina R, Huber K, Jin J, Melino M, Goette A, Lip GYH. Comparing TEE- vs Non-TEE-guided cardioversion of atrial fibrillation: The ENSURE-AF trial. Eur J Clin Invest 2020; 50:e13221. [PMID: 32150758 DOI: 10.1111/eci.13221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/16/2020] [Accepted: 03/07/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND ENSURE-AF (NCT02072434) assessed therapy with edoxaban vs enoxaparin-warfarin in patients with nonvalvular atrial fibrillation (AF) undergoing elective electrical cardioversion (ECV). OBJECTIVES To evaluate clinical features and primary efficacy (composite of stroke, systemic embolic events, myocardial infarction and cardiovascular mortality during study period) and safety endpoints (composite of major and clinically relevant nonmajor bleeding during on-treatment period) in patients awaiting ECV of AF with a transesophageal echocardiography (TEE)-guided vs a non-TEE-guided strategy. METHODS In this prospective, randomized, open-label, blinded endpoint study, 2199 patients were randomized to edoxaban 60 mg once-daily (30 mg for creatinine clearance 15-50 mL/min, weight ≤60 kg and/or concomitant use of P-glycoprotein inhibitor) or enoxaparin-warfarin. Primary efficacy endpoint and safety endpoint were reported. Associates of TEE use, efficacy endpoint and safety endpoint were explored using multivariable logistic regression. RESULTS In total, 589 patients from the edoxaban stratum and 594 from the enoxaparin-warfarin stratum were allocated to the TEE-guided strategy. Primary efficacy was similar regardless of TEE approach (P = .575). There were no significant differences in bleeding rates, regardless of TEE approach (P = .677). Independent predictors of TEE use were as follows: history of ischaemic stroke/ transient ischaemic attack, hypertension and valvular heart disease. Mean CHA2 DS2 VASc and HAS-BLED score were independent predictors of the efficacy endpoint whilst mean age was an independent predictor of the safety endpoint. CONCLUSIONS Thromboembolic and bleeding events were not different between patients undergoing TEE-guided strategy and in those undergoing an optimized conventional anticoagulation approach for ECV of AF.
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Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Division of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Jose L Merino
- Arrhythmia and Robotic Electrophysiology Unit, Hospital Universitario La Paz, Universidad Europea, Madrid, Spain
| | | | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Medical School, Sigmund Freud University, Vienna, Austria
| | - James Jin
- Daiichi Sankyo, Inc., Basking Ridge, NJ, USA
| | | | - Andreas Goette
- St. Vincenz-Hospital, Paderborn, Paderborn, Germany and Working Group: Molecular Electrophysiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Division of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Omae T, Koh K, Kumemura M, Sakuraba S, Katsuda Y. Perioperative management of patients with atrial fibrillation receiving anticoagulant therapy. J Anesth 2019; 33:551-561. [PMID: 31069541 DOI: 10.1007/s00540-019-02653-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 05/03/2019] [Indexed: 12/16/2022]
Abstract
The number of patients with atrial fibrillation (AF) and the number of patients indicated for anticoagulant therapy have been increasing because AF would affect patient survival due to thromboembolism. Once AF develops, following the disappearance of pulsation, the circumstances within the atrium become prothrombotic and thrombus formation within the left atrium occurs in patients with AF. In recent years, not only warfarin but also new oral anticoagulants were introduced clinically and have become used as oral anticoagulants. In the perioperative period, the risk of major hemorrhage needs to be reduced. On the other hand, the suspension of anticoagulant therapy and neutralization of anticoagulant effects elevate the risk of thrombosis. The perioperative management of patients receiving anticoagulant therapy is different from that of scheduled surgery and emergency surgery. In addition, knowledge of the characteristics of each oral anticoagulant is required at drug cessation and resumption. Unlike warfarin, which has been used in the past five decades, direct oral anticoagulants (DOACs) do not have sensitive indicators such as prothrombin time-international normalized ratio. To avoid major hemorrhages and thromboembolism, quantitative assays can be implemented for DOAC monitoring and for reversal therapies in perioperative settings.
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Affiliation(s)
- Takeshi Omae
- Department of Anesthesiology and Pain Clinic, Juntendo University Shizuoka Hospital, Izunokuni, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan.
| | - Keito Koh
- Department of Anesthesiology and Pain Clinic, Juntendo University Shizuoka Hospital, Izunokuni, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan
| | - Masateru Kumemura
- Department of Anesthesiology and Pain Clinic, Juntendo University Shizuoka Hospital, Izunokuni, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan
| | - Sonoko Sakuraba
- Department of Anesthesiology and Pain Clinic, Juntendo University Shizuoka Hospital, Izunokuni, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan
| | - Yosuke Katsuda
- Department of Anesthesiology and Pain Clinic, Juntendo University Shizuoka Hospital, Izunokuni, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan
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Jankajova M, Kubikova L, Valocik G, Candik P, Mitro P, Kurecko M, Sabol F, Kolesar A, Kubikova M, Vachalcova M, Dvoroznakova M. Left atrial appendage strain rate is associated with documented thromboembolism in nonvalvular atrial fibrillation. Wien Klin Wochenschr 2019; 131:156-164. [PMID: 30824998 DOI: 10.1007/s00508-019-1469-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 02/07/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND The left atrial appendage (LAA) strain and strain rate have not yet been studied in the prediction of cardiac thromboembolism. Therefore, this study aimed to evaluate the significance of LAA strain and strain rate as assessed by speckle-tracking imaging in relation to documented thromboembolic events. METHODS A group of 80 patients with a mean age of 65 years who were referred for electrical cardioversion of nonvalvular atrial fibrillation was retrospectively analyzed. Each patient underwent 2D transesophageal echocardiography (TEE). Velocity vector imaging (VVI)-derived LAA strain and strain rate in parallel with other conventional TEE predictors were analyzed in terms of their association with previous embolic stroke and peripheral embolization. RESULTS By comparing the two groups of patients with (22/80) and without embolic events (58/80), patients with embolic events were older, had higher CHA2DS2-VASc scores, higher incidence of coronary artery disease and LAA thrombi, and worse LAA strain and strain rate. Moreover, patients without embolization more often used anticoagulants than patients with embolic events. After adjusting for the abovementioned embolic risk factors, only the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [double weight], diabetes mellitus, stroke [double weight], vascular disease, age from 65 to 74 years, sex category) score and the LAA strain rate remained as significant predictors of embolic events. CONCLUSION The results of the study show that the VVI-derived LAA strain rate is a significant predictor of documented ischemic stroke and systemic thromboembolism in patients with nonvalvular atrial fibrillation. Its predictive power is similar to the predictive power of the CHA2DS2-VASc score.
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Affiliation(s)
- Monika Jankajova
- East-Slovak Institute of Cardiovascular Diseases and Medical Faculty of Safarik University, Department of Cardiology, Safarik University, Ondavska 8, 040 11, Kosice, Slovakia
| | - Lucia Kubikova
- East-Slovak Institute of Cardiovascular Diseases and Medical Faculty of Safarik University, Department of Cardiology, Safarik University, Ondavska 8, 040 11, Kosice, Slovakia.
| | - Gabriel Valocik
- East-Slovak Institute of Cardiovascular Diseases and Medical Faculty of Safarik University, Department of Cardiology, Safarik University, Ondavska 8, 040 11, Kosice, Slovakia
| | - Peter Candik
- East-Slovak Institute of Cardiovascular Diseases and Medical Faculty of Safarik University, Department of Anesthesiology and Intensive Medicine, Safarik University, Kosice, Slovakia
| | - Peter Mitro
- East-Slovak Institute of Cardiovascular Diseases and Medical Faculty of Safarik University, Department of Cardiology, Safarik University, Ondavska 8, 040 11, Kosice, Slovakia
| | - Marian Kurecko
- East-Slovak Institute of Cardiovascular Diseases and Medical Faculty of Safarik University, Department of Cardiology, Safarik University, Ondavska 8, 040 11, Kosice, Slovakia
| | - Frantisek Sabol
- East-Slovak Institute of Cardiovascular Diseases and Medical Faculty of Safarik University, Department of Cardiac Surgery, Safarik University, Kosice, Slovakia
| | - Adrian Kolesar
- East-Slovak Institute of Cardiovascular Diseases and Medical Faculty of Safarik University, Department of Cardiac Surgery, Safarik University, Kosice, Slovakia
| | - Maria Kubikova
- East-Slovak Institute of Cardiovascular Diseases and Medical Faculty of Safarik University, Department of Vascular Surgery, Safarik University, Kosice, Slovakia
| | - Marianna Vachalcova
- East-Slovak Institute of Cardiovascular Diseases and Medical Faculty of Safarik University, Department of Cardiology, Safarik University, Ondavska 8, 040 11, Kosice, Slovakia
| | - Marianna Dvoroznakova
- East-Slovak Institute of Cardiovascular Diseases and Medical Faculty of Safarik University, Department of Cardiology, Safarik University, Ondavska 8, 040 11, Kosice, Slovakia
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32
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Miyazawa K, Lip GYH. Risk assessment and management of atrial fibrillation patients with left atrial thrombus. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 42:1-3. [PMID: 30488453 DOI: 10.1111/pace.13556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Kazuo Miyazawa
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.,Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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33
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Lip GY, Banerjee A, Boriani G, Chiang CE, Fargo R, Freedman B, Lane DA, Ruff CT, Turakhia M, Werring D, Patel S, Moores L. Antithrombotic Therapy for Atrial Fibrillation. Chest 2018; 154:1121-1201. [DOI: 10.1016/j.chest.2018.07.040] [Citation(s) in RCA: 481] [Impact Index Per Article: 80.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/11/2018] [Accepted: 07/24/2018] [Indexed: 02/08/2023] Open
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Jones CW, Christman Z, Smith CM, Safferman MR, Salzman M, Baston K, Haroz R. Comparison between buprenorphine provider availability and opioid deaths among US counties. J Subst Abuse Treat 2018; 93:19-25. [PMID: 30126537 DOI: 10.1016/j.jsat.2018.07.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/11/2018] [Accepted: 07/11/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Buprenorphine is an effective medication for the treatment of opioid addiction, but current barriers to buprenorphine access limit treatment availability for many patients. We identify and characterize regions within the United States (US) with poor buprenorphine access relative to the observed burden of overdose deaths. METHODS This cross sectional study includes US county-level data on the number of available buprenorphine providers (Substance Abuse and Mental Health Services Administration Buprenorphine Treatment Practitioner Locator) and the number of opioid-related overdose deaths between 2013 and 2015 (Centers for Disease Control and Prevention WONDER Database). Counties with fewer than 10 deaths during this time period were excluded to maintain patient privacy. Population-adjusted county death rates and provider availability were compared to identify locations with high disease burdens and limited buprenorphine access. The presence of significant clustering across the dataset was evaluated using Global Moran's I and zones of significant spatial clusters and anomalies were identified using Local Indicator of Spatial Autocorrelation. RESULTS County data were available for 846 counties from 49 states and the District of Columbia, comprising 83% of the US population. The median number of opioid overdose deaths per county was 20.0 deaths per 100,000 residents (interquartile range 13.4-29.9, range 2.9 to 108.8). The number of buprenorphine providers per 100,000 county residents ranged from 0 to 45, with a median of 5.9 (interquartile range 3.2 to 9.5). Global Moran's I analysis yielded significant clustering in the distribution of both providers and deaths, with notable significant clusters of higher than average providers and deaths in the Northeast, and scattered mismatched regions of lower-than-average providers and higher-than-average deaths across the Southern, Midwestern, and Western US. Graphical analysis of buprenorphine provider availability and overdose burden reveals limited treatment access relative to overdose deaths throughout much of the Midwestern and Southern US. CONCLUSIONS Substantial county-level imbalances between the availability of buprenorphine providers and the burden of opioid overdose deaths are present within the US.
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Affiliation(s)
- Christopher W Jones
- Cooper Medical School of Rowan University, Department of Emergency Medicine, One Cooper Plaza, Camden, NJ 08103, USA.
| | - Zachary Christman
- Department of Geography, Planning, and Sustainability, Rowan University, 201 Mullica Hill Road, Glassboro, NJ 08028, USA.
| | - Christopher M Smith
- Cooper Medical School of Rowan University, Department of Emergency Medicine, One Cooper Plaza, Camden, NJ 08103, USA.
| | - Michelle R Safferman
- Cooper Medical School of Rowan University, Department of Emergency Medicine, One Cooper Plaza, Camden, NJ 08103, USA.
| | - Matthew Salzman
- Cooper Medical School of Rowan University, Department of Emergency Medicine, One Cooper Plaza, Camden, NJ 08103, USA.
| | - Kaitlan Baston
- Cooper Medical School of Rowan University, Department of Internal Medicine, Three Cooper Plaza, Camden, NJ 08103, USA.
| | - Rachel Haroz
- Cooper Medical School of Rowan University, Department of Emergency Medicine, One Cooper Plaza, Camden, NJ 08103, USA.
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Melduni RM, Gersh BJ, Wysokinski WE, Ammash NM, Friedman PA, Hodge DO, Chandrasekaran K, Oh JK, Lee HC. Real-Time Pathophysiologic Correlates of Left Atrial Appendage Thrombus in Patients Who Underwent Transesophageal-Guided Electrical Cardioversion for Atrial Fibrillation. Am J Cardiol 2018; 121:1540-1547. [PMID: 29609898 DOI: 10.1016/j.amjcard.2018.02.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 02/12/2018] [Accepted: 02/26/2018] [Indexed: 11/26/2022]
Abstract
Although current guidelines advocate using the CHA2DS2-VASc score to assess the risk of stroke in patients with atrial fibrillation (AF), compared with transesophageal echocardiography (TEE), its ability to predict left atrial appendage thrombus (LAAT) is limited. We studied 3,324 consecutive patients with sustained AF from our prospective registry of patients who underwent first-time TEE-guided electrical cardioversion (ECV) from May 2000 through March 2012. The association of CHA2DS2-VASc score or TEE risk factors with the occurrence of LAAT was analyzed. The mean (SD) age was 69 (12.5) years and 67% were men. LAAT was identified in 49 (1.5%) during pre-ECV TEE. Compared with patients without LAAT, those with LAAT had lower peak left atrial appendage emptying velocity (LAAEV) (17.2 ± 8.5 vs 36.6 ± 20.8; p <0.001) and left ventricular ejection fraction (LVEF) (39.9 ± 17.6 vs 51.4 ± 13.7; p <0.001); their CHA2DS2-VASc score also was higher, but the difference was not statistically significant (3.6 ± 1.4 vs 3.2 ± 1.6; p = 0.06). Multivariate logistic regression analysis identified an LVEF ≤40% (adjusted odds ratio 2.48, 95% confidence interval 1.38 to 4.46), LAAEV 20.3 to 33.9 cm/s (odds ratio 12.19, 95% confidence interval 1.53 to 96.86), and LAAEV ≤20.2 cm/s as independent predictors of LAAT. An LAAEV cut-point of 20 cm/s and an LVEF ≤40% were optimal for detecting LAAT (sensitivity 75% and 62%; specificity 77% and 75%; area under the curve 0.822 and 0.776, respectively). On follow-up, LAAT was an independent risk factor of subsequent ischemic stroke but did not influence survival. In conclusion, reduced LVEF and reduced LAAEV are important pathophysiologic correlates of left atrial appendage thrombogenesis and subsequent ischemic stroke in patients who underwent TEE-guided ECV for AF.
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Wang NC, Sather MD, Hussain A, Althouse AD, Adelstein EC, Jain SK, Katz WE, Shalaby AA, Voigt AH, Saba S. Oral anticoagulation and left atrial thrombi resolution in nonrheumatic atrial fibrillation or flutter: A systematic review and meta‐analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:767-774. [DOI: 10.1111/pace.13368] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/20/2018] [Accepted: 04/26/2018] [Indexed: 01/26/2023]
Affiliation(s)
- Norman C. Wang
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Matthew D. Sather
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Aliza Hussain
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Andrew D. Althouse
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Evan C. Adelstein
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Sandeep K. Jain
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - William E. Katz
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Alaa A. Shalaby
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Andrew H. Voigt
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
| | - Samir Saba
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh PA USA
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37
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Phan QT, Shin SY, Cho IS, Lee WS, Won H, Sharmin S, Lee DY, Kim TH, Kim CJ, Kim SW. Impact of left atrial appendage closure on cardiac functional and structural remodeling: A difference-in-difference analysis of propensity score matched samples. Cardiol J 2018; 26:519-528. [PMID: 29718529 DOI: 10.5603/cj.a2018.0047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 04/25/2018] [Accepted: 03/19/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Although the safety and efficacy of left atrial (LA) appendage (LAA) closure (LAAC) in nonvalvular atrial fibrillation (NVAF) patients have been well documented in randomized controlled trials and real-world experience, there are limited data in the literature about the impact of LAAC on cardiac remodeling. The aim of the study was to examine the impact of LAAC on cardiac functional and structural remodeling in NVAF patients. METHODS Between March 2014 and November 2016, 47 NVAF patients who underwent LAAC were included in this study (LAAC group). A control group (non-LAAC group) was formed from 141 NVAF patients without LAAC using propensity score matching. The difference-in-difference analysis was used to evaluate the difference in cardiac remodeling between the two groups at baseline and follow-up evaluations. RESULTS The LAAC group had a larger increase in LA dimension, volume and volume index than the non-LAAC group (+3.9 mm, p = 0.001; +9.7 mL, p = 0.006 and +5.9 mL/m2, p = 0.011, respectively). Besides, a significant increase in E and E/e' ratio was also observed in the LAAC group (+14.6 cm/s, p = 0.002 and +2.3, p = 0.028, respectively). Compared with the non-LAAC group, left ventricular (LV) ejection fraction and fractional shortening decreased in LAAC patients, but were statistically insignificant (-3.5%, p = 0.109 and -2.0%, p = 0.167, respectively). CONCLUSIONS There were significant increases in LA size and LV filling pressure among NVAF patients after LAAC. These impacts of LAAC on cardiac functional and structural remodeling may have some clinical implications that need to be addressed in future studies.
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Affiliation(s)
- Quang Tan Phan
- Cardiovascular Center, Chung-Ang University Hospital, Seoul, South Korea. .,Intervention Center, Quang Nam Central General Hospital, Quang Nam, Vietnam.
| | - Seung-Yong Shin
- Cardiovascular Center, Chung-Ang University Hospital, Seoul, South Korea
| | - Ik-Sung Cho
- Cardiovascular Center, Chung-Ang University Hospital, Seoul, South Korea
| | - Wang-Soo Lee
- Cardiovascular Center, Chung-Ang University Hospital, Seoul, South Korea
| | - Hoyoun Won
- Cardiovascular Center, Chung-Ang University Hospital, Seoul, South Korea
| | - Saima Sharmin
- Cardiovascular Center, Chung-Ang University Hospital, Seoul, South Korea
| | - Dong-Young Lee
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Tae-Ho Kim
- Cardiovascular Center, Chung-Ang University Hospital, Seoul, South Korea
| | - Chee-Jeong Kim
- Cardiovascular Center, Chung-Ang University Hospital, Seoul, South Korea
| | - Sang-Wook Kim
- Cardiovascular Center, Chung-Ang University Hospital, Seoul, South Korea
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Schaeffer B, Rüden L, Salzbrunn T, Pinnschmidt HO, Akbulak RÖ, Moser JM, Jularic M, Meyer C, Eickholt C, Sultan A, Lüker J, Steven D, Willems S, Hoffmann BA. Incidence of intracardiac thrombus formation prior to electrical cardioversion in respect to the mode of oral anticoagulation. J Cardiovasc Electrophysiol 2018; 29:537-547. [DOI: 10.1111/jce.13447] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 12/12/2017] [Accepted: 12/15/2017] [Indexed: 01/01/2023]
Affiliation(s)
- Benjamin Schaeffer
- Department of Cardiology - Electrophysiology, University Hospital Hamburg; University Heart Center; Hamburg Germany
| | - Lea Rüden
- Department of Cardiology - Electrophysiology, University Hospital Hamburg; University Heart Center; Hamburg Germany
| | - Tim Salzbrunn
- Department of Cardiology - Electrophysiology, University Hospital Hamburg; University Heart Center; Hamburg Germany
| | - Hans O. Pinnschmidt
- Department of Medical Biometry and Epidemiology; University Hospital Hamburg; Hamburg Germany
| | - Ruken Özge Akbulak
- Department of Cardiology - Electrophysiology, University Hospital Hamburg; University Heart Center; Hamburg Germany
| | - Julia Magdalena Moser
- Department of Cardiology - Electrophysiology, University Hospital Hamburg; University Heart Center; Hamburg Germany
| | - Mario Jularic
- Department of Cardiology - Electrophysiology, University Hospital Hamburg; University Heart Center; Hamburg Germany
| | - Christian Meyer
- Department of Cardiology - Electrophysiology, University Hospital Hamburg; University Heart Center; Hamburg Germany
| | - Christian Eickholt
- Department of Cardiology - Electrophysiology, University Hospital Hamburg; University Heart Center; Hamburg Germany
| | - Arian Sultan
- Department of Cardiology - Electrophysiology; University Hospital Cologne; Cologne Germany
| | - Jakob Lüker
- Department of Cardiology - Electrophysiology; University Hospital Cologne; Cologne Germany
| | - Daniel Steven
- Department of Cardiology - Electrophysiology; University Hospital Cologne; Cologne Germany
| | - Stephan Willems
- Department of Cardiology - Electrophysiology, University Hospital Hamburg; University Heart Center; Hamburg Germany
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Dillinger JG, Aleil B, Cheggour S, Benhamou Y, Béjot Y, Marechaux S, Delluc A, Bertoletti L, Lellouche N. Dosing issues with non-vitamin K antagonist oral anticoagulants for the treatment of non-valvular atrial fibrillation: Why we should not underdose our patients. Arch Cardiovasc Dis 2018; 111:85-94. [DOI: 10.1016/j.acvd.2017.04.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 03/08/2017] [Accepted: 04/19/2017] [Indexed: 12/13/2022]
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Gloekler S, Hajredini B, Rycerz S, Jäckle S, Jung W. [Left atrial appendage clusure in nonvalvular atrial fibrillation : Clinical evidence 2017]. Herzschrittmacherther Elektrophysiol 2017; 28:366-380. [PMID: 29143099 DOI: 10.1007/s00399-017-0536-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 10/05/2017] [Indexed: 06/07/2023]
Abstract
Nonvalvular atrial fibrillation (AF) is the most common arrhythmia with a prevalence of 1-2% and affects approximately 15-20% of all octogenarians. Patients are at increased risk of thromboembolic stroke, with an overall risk of 5% per year. Thrombi form almost exclusively in the left atrial appendage (LAA), a blind sac-like heterogeneous structure trabeculated by pectinate muscles. In the past five decades, life-long oral anticoagulation (OAC) with vitamin K antagonists (VKA) has been the state-of-the art treatment to prevent stroke and systemic embolism from thrombi in AF. In the last decade, nonvitamin K dependent oral anticoagulants (NOAC) have been shown to be superior to VKA. Given the safety issues of indefinite OAC with either VKA or NOAC, it is plausible to consider left atrial appendage closure (LAAC) as an alternative strategy to prevent death, stroke or other systemic embolization, and bleeding. In recent years, LAAC has been compared to VKA in prospective randomized trials, yielding superior results regarding efficacy and noninferiority regarding safety in the mid-term. This review provides an update on the current state of LAAC in the field of prevention of death, stroke, and bleedings in patients suffering from nonvalvular AF. We elucidate the evidence and limitations of anticoagulation as the classical treatment paradigm, and review devices and techniques for LAAC. Most importantly, the current clinical evidence on efficacy and safety is outlined.
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Affiliation(s)
- Steffen Gloekler
- Klinik für Innere Medizin III, Kardiologie, Schwarzwald-Baar-Klinikum, 78052, Villingen-Schwenningen, Deutschland.
| | - Bajram Hajredini
- Klinik für Innere Medizin III, Kardiologie, Schwarzwald-Baar-Klinikum, 78052, Villingen-Schwenningen, Deutschland
| | - Simon Rycerz
- Klinik für Innere Medizin III, Kardiologie, Schwarzwald-Baar-Klinikum, 78052, Villingen-Schwenningen, Deutschland
| | - Sebastian Jäckle
- Klinik für Innere Medizin III, Kardiologie, Schwarzwald-Baar-Klinikum, 78052, Villingen-Schwenningen, Deutschland
| | - Werner Jung
- Klinik für Innere Medizin III, Kardiologie, Schwarzwald-Baar-Klinikum, 78052, Villingen-Schwenningen, Deutschland
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Gloekler S, Saw J, Koskinas KC, Kleinecke C, Jung W, Nietlispach F, Meier B. Left atrial appendage closure for prevention of death, stroke, and bleeding in patients with nonvalvular atrial fibrillation. Int J Cardiol 2017; 249:234-246. [DOI: 10.1016/j.ijcard.2017.08.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 08/11/2017] [Accepted: 08/17/2017] [Indexed: 01/06/2023]
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Lip GY, Freedman B, De Caterina R, Potpara TS. Stroke prevention in atrial fibrillation: Past, present and future. Thromb Haemost 2017; 117:1230-1239. [DOI: 10.1160/th16-11-0876] [Citation(s) in RCA: 289] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 06/09/2017] [Indexed: 01/05/2023]
Abstract
SummaryConcepts and our approaches to stroke prevention in atrial fibrillation (AF) have changed markedly over the last decade. There has been an evolution over the approach to stroke and bleeding risk assessment, as well as new treatment options. An increasing awareness of AF has led to calls to improve the detection of and population screening for AF. Stroke and bleeding risk assessment continues to evolve, and the ongoing debate on balance between simplicity and practicality, against precision medicine will continue. In this review article, we provide an overview of past, present and the (likely) future concepts and approaches to stroke prevention in AF. We propose three simple steps (the Birmingham ‘3-step’) that offers a practical management pathway to help streamline and simplify decision-making for stroke prevention in patients with AF.Note: The review process for this paper was fully handled by Christian Weber, Editor in Chief.
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Guérios ÊE, Chamié F, Montenegro M, Saad EB, Brito FSD, Caramori PA, Simões LC, Oliveira FRAD, Giuliano LC, Tavares CMDF. First results of the Brazilian Registry of Percutaneous Left Atrial Appendage Closure. Arq Bras Cardiol 2017; 109:440-447. [PMID: 29069203 PMCID: PMC5729780 DOI: 10.5935/abc.20170150] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 03/29/2017] [Indexed: 12/14/2022] Open
Abstract
Background Left atrial appendage closure (LAAC) is an effective alternative to oral
anticoagulation (OA) for the prevention of stroke in patients with
non-valvular atrial fibrillation (NVAF). Objective To present the immediate results and late outcomes of patients submitted to
LAAC and included in the Brazilian Registry of Percutaneous Left Atrial
Appendage Closure. Methods 91 patients with NVAF, high stroke risk (CHA2DS2VASc
score = 4.5 ± 1.5) and restrictions to OAC (HAS-BLED score = 3.6
± 1.0) underwent 92 LAAC procedures using either the Amplatzer
cardiac plug or the Watchman device in 11 centers in Brazil, between late
2010 and mid 2016. Results Ninety-six devices were used (1.04 device/procedure, including an additional
non-dedicated device), with a procedural success rate of 97.8%. Associated
procedures were performed in 8.7% of the patients. Complete LAAC was
obtained in 93.3% of the successful cases. In cases of incomplete closure,
no residual leak was larger than 2.5 mm. One patient needed simultaneous
implantation of 2 devices. There were 7 periprocedural major (5 pericardial
effusions requiring pericardiocentesis, 1 non-dedicated device embolization
and 1 coronary air embolism without sequelae) and 4 minor complications.
After 128.6 patient-years of follow-up there were 3 deaths unrelated to the
procedure, 2 major bleedings (one of them in a patient with an unsuccessful
LAAC), thrombus formation over the device in 2 cases (both resolved after
resuming OAC for 3 months) and 2 strokes (2.2%). Conclusions In this multicenter, real world registry, that included patients with NVAF
and high thromboembolic and bleeding risks, LAAC effectively prevented
stroke and bleeding when compared to the expected rates based on
CHA2DS2VASc and HASBLED scores for this
population. Complications rate of the procedure was acceptable considering
the beginning of the learning curve of most of the involved operators.
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Affiliation(s)
| | - Francisco Chamié
- Hospital dos Servidores do Estado do Rio de Janeiro, Rio de Janeiro, RJ - Brasil
| | - Márcio Montenegro
- Instituto Estadual de Cardiologia Aloysio de Castro (IECAC), Rio de Janeiro, RJ - Brasil
| | | | | | - Paulo Avancini Caramori
- Centro de Pesquisa Cardiovasculares do Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS - Brasil
| | - Luiz Carlos Simões
- Instituto Nacional de Cardiologia (INC - MS), Rio de Janeiro, RJ - Brasil
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Kurfirst V, Mokráček A, Čanádyová J, Bulava A, Pešl L. Effectivity of left atrial appendage occlusion with AtriClip in 155 consecutive patients - Single center study. COR ET VASA 2017. [DOI: 10.1016/j.crvasa.2017.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Fu Y, Li K, Yang X. ABO blood groups: A risk factor for left atrial and left atrial appendage thrombogenic milieu in patients with non-valvular atrial fibrillation. Thromb Res 2017; 156:45-50. [PMID: 28582641 DOI: 10.1016/j.thromres.2017.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 04/28/2017] [Accepted: 05/20/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Previous studies have identified ABO blood groups as predictors of thromboembolic diseases. In patients with atrial fibrillation (AF), however, potential association between ABO blood groups and the risk of left atrial (LA) and/or left atrial appendage (LAA) thrombogenic milieu (TM) has not been established. METHODS This is a retrospective case-control study that included 125 consecutive patients with non-valvular atrial fibrillation (NVAF) plus TM, as evidenced by transesophageal echocardiography (TEE) during a period from1 January 2010 to 31 December 2016. The controls were selected randomly from 1072 NVAF without TM at a 1:2 ratio. Potential association between ABO blood groups and TM was analyzed using multivariate logistic regression analysis. RESULTS The risk of TM was higher in patients with blood group A (33.6% vs. 20.2% in non-A blood groups, P=0.005). After adjusting for age, sex, oral anticoagulant use, AF type and duration, and relevant functional measures (e.g., NT-pro BNP level, left atrium diameter, and left ventricular ejection fraction), blood group A remained associated with an increased risk of TM (OR=2.99, 95% CI 1.4-6.388, P=0.005). CONCLUSION Blood group A is an independent risk factor for TM in NVAF patients.
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Affiliation(s)
- Yuan Fu
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Kuibao Li
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xinchun Yang
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China.
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RODRIGUEZ YASSER, ALTHOUSE ANDREWD, ADELSTEIN EVANC, JAIN SANDEEPK, MENDENHALL GEORGESTUART, SABA SAMIR, SHALABY ALAAA, VOIGT ANDREWH, WANG NORMANC. Characteristics and Outcomes of Concurrently Diagnosed New Rapid Atrial Fibrillation or Flutter and New Reduced Ejection Fraction. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:1394-1403. [DOI: 10.1111/pace.12981] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/13/2016] [Indexed: 11/30/2022]
Affiliation(s)
- YASSER RODRIGUEZ
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - ANDREW D. ALTHOUSE
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - EVAN C. ADELSTEIN
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - SANDEEP K. JAIN
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | | | - SAMIR SABA
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - ALAA A. SHALABY
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - ANDREW H. VOIGT
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - NORMAN C. WANG
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
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Shahid F, Shantsila E, Lip GYH. Recent advances in the understanding and management of atrial fibrillation: a focus on stroke prevention. F1000Res 2016; 5:2887. [PMID: 28105320 PMCID: PMC5224684 DOI: 10.12688/f1000research.10176.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2016] [Indexed: 12/29/2022] Open
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke compared with the general population. It is anticipated that by 2030 an estimated 14-17 million patients will be diagnosed with this most prevalent arrhythmia within the European Union. AF-related stroke confers a higher mortality and morbidity risk, and thus early detection and assessment for the initiation of effective stroke prevention with oral anticoagulation (OAC) is crucial. Recent guidelines point to the use of non-vitamin K antagonist OACs (NOACs) where appropriate in stroke prevention of patients with non-valvular AF. At present, there are four NOACS available, with no direct head-to-head comparisons to suggest the superiority of one drug over another. Simple and practical risk assessment tools have evolved over the years to facilitate stroke and bleeding risk assessment in busy clinics and wards to aid decision-making. At present, the CHA 2DS 2VASc (congestive heart failure, hypertension, age 65-74/>75, diabetes mellitus, stroke/transient ischemic attack/thromboembolism, vascular disease, female sex) score is recommended by many international guidelines as a simple and practical method of assessing stroke risk in such patients. Alongside this, use of the HAS BLED (hypertension systolic blood pressure >160 mmHg, abnormal liver/renal function [with creatinine ≥200 μmol/L], stroke, bleeding history or predisposition, labile international normalized ratio [range <60% of the time], elderly [>65], concomitant drugs/alcohol) score aims to identify patients at high risk of bleeding for more regular review and follow-up and draws attention to potentially reversible bleeding risk factors. The aim of this review article is to provide an overview of recent advances in the understanding and management of AF with a focus on stroke prevention.
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Affiliation(s)
- Farhan Shahid
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK
| | - Eduard Shantsila
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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48
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Budera P, Straka Z. Cardiac surgery interventions for stroke prevention in patients with atrial fibrillation. COR ET VASA 2016. [DOI: 10.1016/j.crvasa.2016.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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