Transesophageal echocardiographic correlates of clinical risk of thromboembolism in nonvalvular atrial fibrillation. Stroke Prevention in Atrial Fibrillation III Investigators
M Zabalgoitia,
JL Halperin,
LA Pearce,
JL Blackshear,
RW Asinger,
and
RG Hart
University of Texas Health Science Center at San Antonio, 78284-7872, USA. zabalgoitia@uthscsa.edu
OBJECTIVES: This study explored the mechanisms linking clinical and precordial echocardiographic predictors to thromboembolism in atrial fibrillation (AF) by assessing transesophageal echocardiographic (TEE) correlations. BACKGROUND: Clinical predictors of thromboembolism in patients with nonvalvular AF have been identified, but their mechanistic links remain unclear. TEE provides imaging of the left atrium, its appendage and the proximal thoracic aorta, potentially clarifying stroke mechanisms in patients with AF. METHODS: Cross-sectional analysis of TEE features correlated with low, moderate and high thromboembolic risk during aspirin therapy among 786 participants undergoing TEE on entry into the Stroke Prevention in Atrial Fibrillation III trial. RESULTS: TEE features independently associated with increased thromboembolic risk were appendage thrombi (relative risk [RR] 2.5, p = 0.04), dense spontaneous echo contrast (RR 3.7, p < 0.001), left atrial appendage peak flow velocities < or = 20 cm/s (RR 1.7, p = 0.008) and complex aortic plaque (RR 2.1, p < 0.001). Patients with AF with a history of hypertension (conferring moderate risk) more frequently had atrial appendage thrombi (RR 2.6, p < 0.001) and reduced flow velocity (RR 1.8, p = 0.003) than low risk patients. Among low risk patients, those with intermittent AF had similar TEE features to those with constant AF. CONCLUSIONS: TEE findings indicative of atrial stasis or thrombosis and of aortic atheroma were independently associated with high thromboembolic risk in patients with AF. The increased stroke risk associated with a history of hypertension in AF appears to be mediated primarily through left atrial stasis and thrombi. The presence of complex aortic plaque distinguished patients with AF at high risk from those at moderate risk of thromboembolism.
This article has been cited by other articles:
|
|
|
|
 
S. Puwanant, B. C. Varr, K. Shrestha, S. K. Hussain, W.H. W. Tang, R. S. Gabriel, O. M. Wazni, M. Bhargava, W. I. Saliba, J. D. Thomas, et al.
Role of the CHADS(2) Score in the Evaluation of Thromboembolic Risk in Patients With Atrial Fibrillation Undergoing Transesophageal Echocardiography Before Pulmonary Vein Isolation.
J. Am. Coll. Cardiol.,
November 24, 2009;
54(22):
2032 - 2039.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. A. Crandall, D. J. Bradley, D. L. Packer, and S. J. Asirvatham
Contemporary Management of Atrial Fibrillation: Update on Anticoagulation and Invasive Management Strategies
Mayo Clin. Proc.,
July 1, 2009;
84(7):
643 - 662.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. G. Hart and L. A. Pearce
Current Status of Stroke Risk Stratification in Patients With Atrial Fibrillation
Stroke,
July 1, 2009;
40(7):
2607 - 2610.
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Kleemann, T. Becker, M. Strauss, S. Schneider, and K. Seidl
Prevalence and clinical impact of left atrial thrombus and dense spontaneous echo contrast in patients with atrial fibrillation and low CHADS2 score
Eur J Echocardiogr,
May 1, 2009;
10(3):
383 - 388.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Uretsky, A. Shah, S. Bangalore, L. Rosenberg, R. Sarji, D. R. Cantales, D. Macmillan-Marotti, F. A. Chaudhry, and M. V. Sherrid
Assessment of left atrial appendage function with transthoracic tissue Doppler echocardiography
Eur J Echocardiogr,
May 1, 2009;
10(3):
363 - 371.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. M. Hylek, L. Frison, L. E. Henault, and A. Cupples
Disparate Stroke Rates on Warfarin Among Contemporaneous Cohorts With Atrial Fibrillation: Potential Insights Into Risk From a Comparative Analysis of SPORTIF III Versus SPORTIF V
Stroke,
November 1, 2008;
39(11):
3009 - 3014.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. S. Gabriel and A. L. Klein
Managing catheter ablation for atrial fibrillation: the role of echocardiography
Europace,
November 1, 2008;
10(suppl_3):
iii8 - iii13.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. H. Hohnloser, G. Z. Duray, U. Baber, and J. L. Halperin
Prevention of stroke in patients with atrial fibrillation: current strategies and future directions
Eur. Heart J. Suppl.,
September 1, 2008;
10(suppl_H):
H4 - H10.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Cohen, S. Ederhy, C. Meuleman, E. Di Angelantonio, G. Dufaitre, and F. Boccara
D-dimers in atrial fibrillation: a further step in risk stratification of thrombo-embolism?
Eur. Heart J.,
September 2, 2007;
28(18):
2179 - 2180.
[Full Text]
[PDF]
|
|
|
|
|
|
|
The Stroke Risk in Atrial Fibrillation Working Gro
Independent predictors of stroke in patients with atrial fibrillation: A systematic review
Neurology,
August 7, 2007;
69(6):
546 - 554.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. B. Sick, G. Schuler, K. E. Hauptmann, E. Grube, S. Yakubov, Z. G. Turi, G. Mishkel, S. Almany, and D. R. Holmes
Initial Worldwide Experience With the WATCHMAN Left Atrial Appendage System for Stroke Prevention in Atrial Fibrillation
J. Am. Coll. Cardiol.,
April 3, 2007;
49(13):
1490 - 1495.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. Y.H. Lip, L. Frison, M. Grind, and on behalf of the SPORTIF Investigators
Effect of hypertension on anticoagulated patients with atrial fibrillation
Eur. Heart J.,
March 2, 2007;
28(6):
752 - 759.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R I Dewar, G Y H Lip, and on behalf of the Guidelines Development Group for
Identification, diagnosis and assessment of atrial fibrillation
Heart,
January 1, 2007;
93(1):
25 - 28.
[Full Text]
[PDF]
|
|
|
|
|
|
|
Writing Committee Members, V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, et al.
ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: full text: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society
Europace,
September 1, 2006;
8(9):
651 - 745.
[Full Text]
[PDF]
|
|
|
|
|
|
|
V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, J. E. Lowe, et al.
ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society
J. Am. Coll. Cardiol.,
August 15, 2006;
48(4):
854 - 906.
[Full Text]
[PDF]
|
|
|
|
|
|
|
V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, J. E. Lowe, et al.
ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society
J. Am. Coll. Cardiol.,
August 15, 2006;
48(4):
e149 - e246.
[Full Text]
[PDF]
|
|
|
|
|
|
|
V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, J. E. Lowe, et al.
ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society
Circulation,
August 15, 2006;
114(7):
e257 - e354.
[Full Text]
[PDF]
|
|
|
|
|
|
|
V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, J. E. Lowe, et al.
ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society
Circulation,
August 15, 2006;
114(7):
700 - 752.
[Full Text]
[PDF]
|
|
|
|
|
|
|
Authors/Task Force Members, V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, et al.
ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation executive summary: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society
Eur. Heart J.,
August 2, 2006;
27(16):
1979 - 2030.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Q. Melo
Surgery for atrial fibrillation: Are we heading in the right direction?
J. Thorac. Cardiovasc. Surg.,
May 1, 2006;
131(5):
949 - 951.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Harloff, M. Handke, M. Reinhard, A. Geibel, and A. Hetzel
Therapeutic Strategies After Examination by Transesophageal Echocardiography in 503 Patients With Ischemic Stroke
Stroke,
March 1, 2006;
37(3):
859 - 864.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. Arima, R. G. Hart, S. Colman, J. Chalmers, C. Anderson, A. Rodgers, M. Woodward, S. MacMahon, B. Neal, and for the PROGRESS Collaborative Group
Perindopril-Based Blood Pressure-Lowering Reduces Major Vascular Events in Patients With Atrial Fibrillation and Prior Stroke or Transient Ischemic Attack
Stroke,
October 1, 2005;
36(10):
2164 - 2169.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. A. Boyajian, S. M. Otis, B. F. Gage, C. van Walraven, L. Pearce, R. G. Hart, P. J. Koudstaal, B.S.P. Boode, and P. Petersen
Letter Regarding Article by Gage et al, "Selecting Patients With Atrial Fibrillation for Anticoagulation: Stroke Risk Stratification in Patients Taking Aspirin" * Response
Circulation,
June 28, 2005;
111(25):
e455 - e456.
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. Bernhardt, H. Schmidt, C. Hammerstingl, B. Luderitz, and H. Omran
Patients With Atrial Fibrillation and Dense Spontaneous Echo Contrast at High Risk: A Prospective and Serial Follow-Up Over 12 Months With Transesophageal Echocardiography and Cerebral Magnetic Resonance Imaging
J. Am. Coll. Cardiol.,
June 7, 2005;
45(11):
1807 - 1812.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
O A Obel, L Luddington, N Maarouf, K Aytemir, C Ekwall, M Malik, and A J Camm
Effects of ventricular rate and regularity on the velocity and magnitude of left atrial appendage flow in atrial fibrillation
Heart,
June 1, 2005;
91(6):
764 - 768.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. G. Sherman, S. G. Kim, B. S. Boop, S. D. Corley, J. P. DiMarco, R. G. Hart, L. J. Haywood, K. Hoyte, E. S. Kaufman, M. H. Kim, et al.
Occurrence and Characteristics of Stroke Events in the Atrial Fibrillation Follow-up Investigation of Sinus Rhythm Management (AFFIRM) Study
Arch Intern Med,
May 23, 2005;
165(10):
1185 - 1191.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. F. Scholten, A. S. Thornton, J. M. Mekel, P. J. Koudstaal, and L. J. Jordaens
Anticoagulation in atrial fibrillation and flutter
Europace,
January 1, 2005;
7(5):
492 - 499.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. Inoue, T. Nozawa, K. Okumura, L. Jong-Dae, A. Shimizu, and K. Yano
Prothrombotic Activity Is Increased in Patients With Nonvalvular Atrial Fibrillation and Risk Factors for Embolism
Chest,
September 1, 2004;
126(3):
687 - 692.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. L. McNamara, L. J. Tamariz, J. B. Segal, and E. B. Bass
Management of Atrial Fibrillation: Review of the Evidence for the Role of Pharmacologic Therapy, Electrical Cardioversion, and Echocardiography
Ann Intern Med,
December 16, 2003;
139(12):
1018 - 1033.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. E. Singer
A 60-Year-Old Woman With Atrial Fibrillation
JAMA,
October 22, 2003;
290(16):
2182 - 2189.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Castello and T. G. Brott
Patent foramen ovale: friend or foe?
J. Am. Coll. Cardiol.,
September 17, 2003;
42(6):
1073 - 1075.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Takami, M. Suzuki, K. Sugi, and T. Ikeda
Time course for resolution of left atrial appendage stunning after catheter ablation of chronic atrial flutter
J. Am. Coll. Cardiol.,
June 18, 2003;
41(12):
2207 - 2211.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. G. Hart, J. L. Halperin, L. A. Pearce, D. C. Anderson, R. A. Kronmal, R. McBride, E. Nasco, D. G. Sherman, R. L. Talbert, J. R. Marler, et al.
Lessons from the Stroke Prevention in Atrial Fibrillation Trials
Ann Intern Med,
May 20, 2003;
138(10):
831 - 838.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S Illien, S Maroto-Jarvinen, G von der Recke, C Hammerstingl, H Schmidt, S Kuntz-Hehner, B Luderitz, and H Omran
Atrial fibrillation: relation between clinical risk factors and transoesophageal echocardiographic risk factors for thromboembolism
Heart,
February 1, 2003;
89(2):
165 - 168.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. S.G. Conway, L. A. Pearce, B. S.P. Chin, R. G. Hart, and G. Y.H. Lip
Plasma von Willebrand Factor and Soluble P-Selectin as Indices of Endothelial Damage and Platelet Activation in 1321 Patients With Nonvalvular Atrial Fibrillation: Relationship to Stroke Risk Factors
Circulation,
October 8, 2002;
106(15):
1962 - 1967.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
V. Fuster, L. E. Ryden, R. W. Asinger, D. S. Cannom, H. J. Crijns, R. L. Frye, J. L. Halperin, G. N. Kay, W. W. Klein, S. Levy, et al.
ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology
Circulation,
October 23, 2001;
104(17):
2118 - 2150.
[Full Text]
[PDF]
|
|
|
|
|
|
|
Guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology
Eur. Heart J.,
October 2, 2001;
22(20):
1852 - 1923.
[PDF]
|
|
|
|
|
|
|
V. Fuster, L. E. Ryden, R. W. Asinger, D. S. Cannom, H. J. Crijns, R. L. Frye, J. L. Halperin, G. N. Kay, W. W. Klein, S. Levy, et al.
ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary: A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology
J. Am. Coll. Cardiol.,
October 1, 2001;
38(4):
1231 - 1265.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A Fyrenius, L Wigstrom, T Ebbers, M Karlsson, J Engvall, and A F Bolger
Three dimensional flow in the human left atrium
Heart,
October 1, 2001;
86(4):
448 - 455.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
N. Shinokawa, T. Hirai, S. Takashima, T. Kameyama, K. Nakagawa, H. Asanoi, and H. Inoue
A Transesophageal Echocardiographic Study on Risk Factors for Stroke in Elderly Patients With Atrial Fibrillation : A Comparison With Younger Patients
Chest,
September 1, 2001;
120(3):
840 - 846.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. El Gendi, B. Wasan, J. Mayet, D. M. Gilligan, and R. H. Falk
Atrial Fibrillation
N. Engl. J. Med.,
August 23, 2001;
345(8):
620 - 621.
[Full Text]
[PDF]
|
|
|
|
|
|
|
G Corrado, A Sgalambro, A Mantero, F Gentile, M Gasparini, R Bufalino, A Morabito, G Trocino, R Schiavina, S Mandorla, et al.
Thromboembolic risk in atrial flutter. The FLASIEC (FLutterAtrialeSocietaIaliana diEcografiaCardiovascolare) multicentre study
Eur. Heart J.,
June 2, 2001;
22(12):
1042 - 1051.
[Abstract]
[PDF]
|
|
|
|
|
|
|
A. L. Klein, R. D. Murray, and R. A. Grimm
Role of transesophageal echocardiography-guided cardioversion of patients with atrial fibrillation
J. Am. Coll. Cardiol.,
March 1, 2001;
37(3):
691 - 704.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. G. Hart and J. L. Halperin
Atrial Fibrillation and Stroke : Concepts and Controversies
Stroke,
March 1, 2001;
32(3):
803 - 808.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. S. Chugh, J. L. Blackshear, W.-K. Shen, S. C. Hammill, and B. J. Gersh
Epidemiology and natural history of atrial fibrillation: clinical implications
J. Am. Coll. Cardiol.,
February 1, 2001;
37(2):
371 - 378.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Y. Yang, D. G. Grosset, Q. Li, and K. R. Lees
Identification Of Echocardiographic "Smoke" in a Bench Model With Transcranial Doppler Ultrasound
Stroke,
April 1, 2000;
31(4):
907 - 914.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. J. M. Barnett, R. W. Gunton, M. Eliasziw, L. Fleming, B. Sharpe, P. Gates, and H. Meldrum
Causes and Severity of Ischemic Stroke in Patients With Internal Carotid Artery Stenosis
JAMA,
March 15, 2000;
283(11):
1429 - 1436.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. A. Burkart and A. B. Curtis
Reviews: Atrial Fibrillation: Current and Future Strategies for Management
Journal of Cardiovascular Pharmacology and Therapeutics,
January 1, 2000;
5(3):
151 - 160.
[PDF]
|
|
|
|
|
|
|
Y. Agmon, B. K. Khandheria, F. Gentile, and J. B. Seward
Echocardiographic assessment of the left atrial appendage
J. Am. Coll. Cardiol.,
December 1, 1999;
34(7):
1867 - 1877.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. G. Hart and J. L. Halperin
Atrial Fibrillation and Thromboembolism: A Decade of Progress in Stroke Prevention
Ann Intern Med,
November 2, 1999;
131(9):
688 - 695.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. L. Blackshear, L. A. Pearce, R. G. Hart, M. Zabalgoitia, A. Labovitz, R. W. Asinger, and J. L. Halperin
Aortic Plaque in Atrial Fibrillation : Prevalence, Predictors, and Thromboembolic Implications
Stroke,
April 1, 1999;
30(4):
834 - 840.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
