title: Thromboembolism in patients with atrial fibrillation with and without left atrial thrombus documented by transesophageal echocardiography.
abstract: The incidence of cerebrovascular events (CVEs) was investigated in 95 consecutive patients with atrial fibrillation (AF) with left atrial thrombus (LAT) diagnosed by transesophageal echocardiography (TEE) and in 131 age- and sex-matched AF patients without LAT. Compared with patients without LAT, patients with LAT had a larger left atrial diameter (49 versus 44 mm, P < 0.0001), a lower left ventricular ejection fraction (40% versus 50%, P < 0.0001), a higher prevalence of spontaneous echocardiographic contrast (88% versus 25%, P < 0.001), a reduced left atrial appendage emptying velocity (0.25 versus 0.41 cm/s, P < 0.0001), and less use of antiarrhythmic drugs (61% versus 76%, P = 0.03). Before TEE, the prevalence of prior CVE was higher in LAT patients (20%) compared with patients without LAT (8%) (P = 0.01). Fifty-four of 95 LAT patients (57%) and 81 of 131 non-LAT patients (62%) were on warfarin before TEE. The incidence of prior CVE in LAT patients without warfarin (32%) was higher than that in non-LAT patients without warfarin (10%) (P = 0.02). The mortality rate in LAT patients with an international normalized ratio (INR) >or= 2.0 (42%) was higher than that in patients without LAT and an INR >or= 2.0 (11%) (P < 0.001). Fifty-one of 95 LAT patients (54%) underwent repeat TEE before cardioversion (48 patients received warfarin therapy). The thrombus resolved in 40 of 51 patients (78%) after the first TEE. There was no significant difference in INR between the patients with persistent and resolved LAT. AF patients with persistent LAT had a higher incidence of CVE (45%) than the patients with resolved LAT (5%) (P = 0.003). We suggest that patients with LAT be treated with warfarin to maintain an INR between 2.5 and 3.5 rather than between 2.0 and 3.0 because they are at a high risk for new thromboembolism.
authors: Cardiac Center, Creighton University, Omaha, NE, USA.
authors: Chandra K
authors: CK
authors: Nair
authors: Mark J
authors: MJ
authors: Holmberg
authors: Wilbert S
authors: WS
authors: Aronow
authors: Xuedong
authors: X
authors: Shen
authors: Huagui
authors: H
authors: Li
authors: Dhanunjay
authors: D
authors: Lakkireddy
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D000925:Anticoagulants / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000150:complications* / Q000000981:diagnostic imaging / Q000188:drug therapy; D016022:Case-Control Studies; D017548:Echocardiography, Transesophageal; D004554:Electric Countershock / Q000379:methods; D005260:Female; D006325:Heart Atria / Q000000981:diagnostic imaging; D006801:Humans; D019934:International Normalized Ratio; D008297:Male; D008875:Middle Aged; D013923:Thromboembolism / Q000000981:diagnostic imaging / Q000209:etiology*; D013927:Thrombosis / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000401:mortality; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000889:Anti-Arrhythmia Agents; D000925:Anticoagulants; D014859:Warfarin