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Katic J, Borovac JA. Treatment of Persistent Left Atrial Appendage Thrombus in Patients with Atrial Fibrillation on Adequate Oral Anticoagulation: Pathways of Care for All-comers and Heart Failure Patients. Card Fail Rev 2023; 9:e05. [PMID: 37397240 PMCID: PMC10311400 DOI: 10.15420/cfr.2022.28] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/27/2023] [Indexed: 07/04/2023] Open
Abstract
In patients with AF, the presence of left atrial/left atrial appendage (LA/LAA) thrombus is related to an increased risk of thromboembolic events. Anticoagulation therapy, either with vitamin K antagonists or novel oral anticoagulants (NOACs) is therefore mandatory in AF with LA/LAA thrombus in order to lower the risk of stroke or other systemic embolic events. Despite the efficacy of these treatments, some patients will have persistent LAA thrombus remaining or may have contraindications to oral anticoagulation. Currently, little is known about the occurrence, risk factors and resolution rate of LA/LAA thrombus in patients who are already under optimal chronic oral anticoagulation, including vitamin K antagonists or NOACs. The common action in clinical practice in this scenario is switching from one to another anticoagulant drug exhibiting a different mechanism of action. Repeated cardiac imaging is then advised within several weeks to visually verify thrombus dissolution. Finally, there is a substantial scarcity of data on the role and optimal use of NOACs after LAA occlusion. The aim of this review is to critically evaluate data and provide up-to-date information on the best antithrombotic strategies in this challenging clinical scenario.
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Affiliation(s)
- Josip Katic
- Cardiovascular Diseases Department, University Hospital of Split Split, Croatia
| | - Josip Andelo Borovac
- Cardiovascular Diseases Department, University Hospital of Split Split, Croatia
- Department of Pathophysiology, University of Split School of Medicine Split, Croatia
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Prevalence and Rate of Resolution of Left Atrial Thrombus in Patients with Non-Valvular Atrial Fibrillation: A Two-Center Retrospective Real-World Study. J Clin Med 2022; 11:jcm11061520. [PMID: 35329845 PMCID: PMC8948620 DOI: 10.3390/jcm11061520] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/27/2022] [Accepted: 03/08/2022] [Indexed: 12/30/2022] Open
Abstract
Background and aim. Thromboembolic events due to left atrial appendage (LAA) thrombosis are the main complication of non-valvular atrial fibrillation (NVAF). Although anticoagulants are effective in patients with NVAF, a minimal residual thromboembolic risk persists. Little is known about the prevalence of LAA thrombus and the rate of resolution after the recommended period of anticoagulation therapy, including vitamin K antagonists (VKA), heparin, and non-vitamin K antagonist oral anticoagulants (NOACs). Methods and results. We aimed to study the prevalence of LAA thrombus in an unselected cohort of patients undergoing transesophageal echocardiogram (TEE), and the determinants of LAA thrombus resolution. We retrospectively analyzed 8888 consecutive TEEs performed over five years in two high-volume centers and included all patients with LAA thrombus. A total of 265 patients (3%) had an LAA thrombus. Among these, 97% presented with AF. Fifty-eight percent of patients were on anticoagulants at least three weeks before the diagnosis. After the LAA thrombus diagnosis, VKAs were prescribed in 52%, heparin in 18.5%, and NOAC in 27% of patients. Among the 183 patients with repeat TEE, performed at (25–75th) 39 days (21–84), 67% showed resolution of the LAA thrombus. Although the rate of thrombus resolution was higher in patients treated with NOACs (NOACs 71%, VKA 66%, Heparin 60%) the difference between anticoagulants was statistically non-significant (VKA, OR 0.9, p = 0.83; NOAC, OR 1.23, p = 0.42; heparin, OR 0.69, p = 0.35). Thus, NOACs were demonstrated to be at least as effective as other anticoagulants in the rate of LAA thrombus resolution. Upon multivariate-adjusted analysis, higher LAA emptying velocities were the only predictor of thrombus resolution. In conclusion, the majority of patients were already on anticoagulants. NOACs could be at least as effective as other anticoagulants, yielding an LAA thrombus resolution in two-thirds of patients. This may have clinical relevance, especially in patients undergoing cardioversion or catheter ablation.
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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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Mumoli N, Amellone C, Antonelli G, Augello G, Cloro C, D’Alleva A, Ascenzo LD, Imbalzano E, Masala R, Riccioni G, Romeo E, Rossi L, Santoro G, Sciatti E, Tondo A, Toso E, Venturini E, Vizzardi E, Mascioli G. Clinical Discussions in Antithrombotic Therapy Management in Patients With Atrial Fibrillation: A Delphi Consensus Panel. CJC Open 2020; 2:641-651. [PMID: 33305224 PMCID: PMC7711025 DOI: 10.1016/j.cjco.2020.07.016] [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: 06/09/2020] [Accepted: 07/17/2020] [Indexed: 12/04/2022] Open
Abstract
Background In recent years, direct-acting oral anticoagulants (DOACs) have entered clinical practice for stroke prevention in non-valvular atrial fibrillation or prevention and treatment of venous thromboembolism. However, remaining uncertainty regarding DOAC use in some clinical scenarios commonly encountered in the real world has not been fully explored in clinical trials. Methods We report on use of a Delphi consensus process on DOAC use in non-valvular atrial fibrillation patients. The consensus process dealt with 9 main topics: (i) DOACs vs vitamin K antagonists in atrial fibrillation (AF) patients; (ii) therapeutic options for patients with stable total time in range treated with vitamin K antagonists; (iii) therapeutic options for patients aged > 85 years; (iv) therapeutic management of hyperfiltering patients; (v) pharmacologic interactions; (vi) therapeutic options in the long-term treatment (prevention) of patients with AF and acute coronary syndrome after the triple therapy; (vii) low doses of DOACs in AF patients; (viii) ischemic stroke in patients inappropriately treated with low doses of DOACs; (ix) management of patients taking DOACs with left atrial appendage thrombosis. Results A total of 101 physicians (cardiologists, internists, geriatricians, and hematologists) from Italy expressed their level of agreement on each statement by using a 5-point Likert scale (1 = strongly disagree; 2 = disagree; 3 = somewhat agree; 4 = agree; 5 = strongly agree). Votes 1-2 were considered to be disagreement; votes 3-5 were considered to be agreement. Agreement among the respondents of ≥ 66% for each statement was considered consensus. A brief discussion of the results for each topic is also reported. Conclusions In clinical practice, there is still uncertainty on DOAC use, especially in elderly, fragile, comorbid, and hyperfiltering patients.
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CHA 2DS 2-VASc Score as a Predictor for Left Atrial Thrombus or Spontaneous Echo Contrast in Patients with Nonvalvular Atrial Fibrillation: A Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2679539. [PMID: 32733935 PMCID: PMC7369682 DOI: 10.1155/2020/2679539] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 06/08/2020] [Accepted: 06/22/2020] [Indexed: 11/28/2022]
Abstract
Objective This meta-analysis aimed at exploring the predictive value of CHA2DS2-VASc score for the left atrial thrombus (LAT) or left atrial spontaneous echo contrast (LASEC) in patients with nonvalvular atrial fibrillation (NVAF). Methods PubMed, Embase, Web of Science, ScienceDirect, Cochrane Library, and Chinese core journals of the CNKI and Wanfang databases were searched to identify all the relevant papers that were published up to January 2020. The data were extracted for pooled odds ratios (ORs) with 95% confidence intervals (CIs), heterogeneity, subgroup, publication bias, and sensitivity analysis. Results Overall, 15 studies containing 6223 patients with NVAF were enrolled. All studies were evaluated for LAT, and 12 studies were evaluated for LASEC. The pooled analysis using a random-effects model showed that a high CHA2DS2-VASc score was related with LAT/LASEC (pooled OR = 1.59, 95% CI: 1.35–1.88, P < 0.001) with high heterogeneity (I2 = 76.9%, P < 0.001) and LAT (pooled OR = 1.83, 95% CI: 1.44–2.33, P < 0.001) with high heterogeneity (I2 = 79.4%, P < 0.001). The subgroup analysis demonstrated that the sample size may be the main source of heterogeneity. Although the Begg's funnel plot based on 15 studies for LAT/LASEC (P = 0.029) and 12 studies for LAT (P = 0.046) indicated the presence of publication bias among the included studies, the trim-and-fill method verified the stability of the pooled outcomes. In addition, sensitivity analysis indicated that all effects were stable. Conclusion The results of this meta-analysis showed that the CHA2DS2-VASc score is related with LAT and LASEC in patients with NVAF. However, more studies are warranted to address this issue.
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Tak BT, Ekizler FA, Cetin EHO, Ozeke O, Cay S, Aras D. Management of left atrium appendage thrombosis in nonvalvular atrial fibrillation patients. Pacing Clin Electrophysiol 2019; 42:1603-1604. [DOI: 10.1111/pace.13809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Bahar Tekin Tak
- Department of CardiologyHealth Sciences University, Ankara City Hospital Ankara Turkey
| | | | | | - Ozcan Ozeke
- Department of CardiologyHealth Sciences University, Ankara City Hospital Ankara Turkey
| | - Serkan Cay
- Department of CardiologyHealth Sciences University, Ankara City Hospital Ankara Turkey
| | - Dursun Aras
- Department of CardiologyHealth Sciences University, Ankara City Hospital Ankara Turkey
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