Transesophageal Echocardiographic Correlates of Thromboembolism in High-Risk Patients with Nonvalvular Atrial Fibrillation
Journal: Annals of Internal Medicine (1998)

Articles15 April 1998Transesophageal Echocardiographic Correlates of Thromboembolism in High-Risk Patients with Nonvalvular Atrial FibrillationAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-128-8-199804150-00005 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail AbstractBackground:Transesophageal echocardiography (TEE) visualizes potential sources of embolism in patients with atrial fibrillation, but the clinical significance of TEE findings has not been prospectively established.Objective:To define TEE predictors of stroke in patients with atrial fibrillation and to examine response to anti-thrombotic therapy.Design:Prospective correlation of TEE findings at study entry with subsequent ischemic stroke during 1.1-year mean follow-up of participants in a randomized trial.Setting:18 echocardiography laboratories.Patients:382 patients with atrial fibrillation at high risk for thromboembolism.Intervention:Adjusted-dose warfarin (international normalized ratio, 2 to 3) or low-intensity warfarin (international normalized ratio, 1.2 to 1.5) plus aspirin (325 mg/d).Measurements:Size of left atrium and left atrial appendage, flow velocity, spontaneous echocardiographic contrast, thrombus, and plaque on the aortic arch.Results:23 ischemic strokes occurred. In patients with dense spontaneous echocardiographic contrast (20%), the rate of stroke was 18.2% per year with combination therapy (2.9 times the rate in patients without this finding; P = 0.06) and 4.5% per year with adjusted-dose warfarin (P = 0.09 for rate reduction). Appendage thrombus, detected in 10% of patients, was associated with dense spontaneous echocardiographic contrast (P < 0.001), was seen more frequently after 2 weeks of combination therapy (15%) than after 2 weeks of adjusted-dose warfarin (4%) (P = 0.004), and tripled the overall rate of stroke (P = 0.04). Patients with complex aortic plaque (35%) had a fourfold increased rate of stroke compared with plaque-free patients (P = 0.005); adjusted-dose warfarin decreased risk by 75% (P = 0.02). Dense spontaneous echocardiographic contrast and complex aortic plaque were independent of each other as predictors of thromboembolism.Conclusions:In high-risk patients with atrial fibrillation, subsequent rates of thromboembolism are correlated with dense spontaneous echocardiographic contrast, thrombus of the atrial appendage, and aortic plaque. Adjusted-dose warfarin reduces the rate of stroke among patients with dense contrast and complex plaque. In patients with atrial fibrillation, the pathogenesis of stroke is multifactorial, and warfarin seems effective for the diverse mechanisms.References1. Predictors of thromboembolism in atrial fibrillation: I. Clinical features of patients at risk. The Stroke Prevention in Atrial Fibrillation Investigators. Ann Intern Med. 1992; 116:1-5. Google Scholar2. Predictors of thromboembolism in atrial fibrillation: II. Echocardiographic features of patients at risk. The Stroke Prevention in Atrial Fibrillation Investigators. 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Google Scholar Author, Article, and Disclosure InformationAffiliations: Acknowledgments: The authors thank the patients enrolled in the Stroke Prevention in Atrial Fibrillation study who willingly underwent transesophageal echocardiography to advance the effort to prevent stroke in persons with atrial fibrillation.Grant Support: By grants R01-NS-33351 and R01-NS-24224 from the U.S. Public Health Service, National Institute of Neurological Disorders and Stroke, National Institutes of Health.Corresponding Author: SPAF Statistical Coordinating Center, Statistics and Epidemiology Research Corp., 1107 NE 45th Street, Suite 520, Seattle, WA 98105. 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