title: Extracranial Systemic Embolic Events in Patients With Nonvalvular Atrial Fibrillation: Incidence, Risk Factors, and Outcomes.
abstract: BACKGROUND
  Nonvalvular atrial fibrillation is a major cause of thromboembolic events. In comparison with atrial fibrillation-related stroke, extracranial systemic embolic events (SEEs) remain poorly defined.
  
  
  RESULTS
  All suspected SEEs reported among 37 973 participants of 4 large contemporary randomized clinical trials of anticoagulation in atrial fibrillation were independently readjudicated for clinical and objective evidence of sudden loss of perfusion of a limb or organ. Over 91 746 patient-years of follow-up, 221 SEEs occurred in 219 subjects. The SEE incidence was 0.24 of 100 and stroke incidence was 1.92 of 100 patient-years. In comparison with patients with stroke, those with SEE were more often female (56% versus 47%; P=0.01) and had comparable mean age (73.1±8.5 versus 73.5±8.8 years; P=0.57) and mean CHADS2 scores (2.4±1.3 versus 2.5±1.2; P=0.33). SEEs more frequently involved the lower extremity (58%) than visceral-mesenteric (31%) or upper extremity (10%). SEE-related care involved clinic assessment alone in 5%, 30% were hospitalized without procedures, 60% underwent endovascular or surgical intervention, and 5% underwent amputation. Within 30 days, 54% of patients recovered fully, 20% survived with deficits, and 25% died. Thirty-day mortality was greater after visceral-mesenteric than lower- or upper-extremity SEE (55%, 17%, and 9%, respectively, P≤0.0001). The relative risk of death throughout follow-up was 4.33 (95% confidence interval, 3.29-5.70) after SEE versus 6.79 (95% confidence interval, 6.22-7.41) after stroke in comparison with patients without either event.
  
  
  CONCLUSIONS
  SEE constituted 11.5% of clinically recognized thromboembolic events in patients with atrial fibrillation and was associated with high morbidity and mortality. SEE mortality was comparable to that of ischemic stroke and varied by anatomic site.
authors.affiliation: From Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis (W.B., S.D., A.T.H.); Department of Medicine, McMaster University, Hamilton, Ontario (S.J.C., S.C., J.P., J.W.E., S.Y.); Mt. Sinai School of Medicine, New York (J.L.H.); Division of Cardiology, Minneapolis Veterans Administration Medical Center, MN (S.A.); Lankenau Institute for Medical Research, Wynnewood, PA (M.D.E.); and Uppsala Clinical Research Center, Sweden (L.G.W.).
authors.forename: Wobo
authors.initials: W
authors.lastname: Bekwelem
authors.affiliation: From Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis (W.B., S.D., A.T.H.); Department of Medicine, McMaster University, Hamilton, Ontario (S.J.C., S.C., J.P., J.W.E., S.Y.); Mt. Sinai School of Medicine, New York (J.L.H.); Division of Cardiology, Minneapolis Veterans Administration Medical Center, MN (S.A.); Lankenau Institute for Medical Research, Wynnewood, PA (M.D.E.); and Uppsala Clinical Research Center, Sweden (L.G.W.).
authors.forename: Stuart J
authors.initials: SJ
authors.lastname: Connolly
authors.affiliation: From Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis (W.B., S.D., A.T.H.); Department of Medicine, McMaster University, Hamilton, Ontario (S.J.C., S.C., J.P., J.W.E., S.Y.); Mt. Sinai School of Medicine, New York (J.L.H.); Division of Cardiology, Minneapolis Veterans Administration Medical Center, MN (S.A.); Lankenau Institute for Medical Research, Wynnewood, PA (M.D.E.); and Uppsala Clinical Research Center, Sweden (L.G.W.).
authors.forename: Jonathan L
authors.initials: JL
authors.lastname: Halperin
authors.affiliation: From Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis (W.B., S.D., A.T.H.); Department of Medicine, McMaster University, Hamilton, Ontario (S.J.C., S.C., J.P., J.W.E., S.Y.); Mt. Sinai School of Medicine, New York (J.L.H.); Division of Cardiology, Minneapolis Veterans Administration Medical Center, MN (S.A.); Lankenau Institute for Medical Research, Wynnewood, PA (M.D.E.); and Uppsala Clinical Research Center, Sweden (L.G.W.).
authors.forename: Selcuk
authors.initials: S
authors.lastname: Adabag
authors.affiliation: From Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis (W.B., S.D., A.T.H.); Department of Medicine, McMaster University, Hamilton, Ontario (S.J.C., S.C., J.P., J.W.E., S.Y.); Mt. Sinai School of Medicine, New York (J.L.H.); Division of Cardiology, Minneapolis Veterans Administration Medical Center, MN (S.A.); Lankenau Institute for Medical Research, Wynnewood, PA (M.D.E.); and Uppsala Clinical Research Center, Sweden (L.G.W.).
authors.forename: Sue
authors.initials: S
authors.lastname: Duval
authors.affiliation: From Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis (W.B., S.D., A.T.H.); Department of Medicine, McMaster University, Hamilton, Ontario (S.J.C., S.C., J.P., J.W.E., S.Y.); Mt. Sinai School of Medicine, New York (J.L.H.); Division of Cardiology, Minneapolis Veterans Administration Medical Center, MN (S.A.); Lankenau Institute for Medical Research, Wynnewood, PA (M.D.E.); and Uppsala Clinical Research Center, Sweden (L.G.W.).
authors.forename: Susan
authors.initials: S
authors.lastname: Chrolavicius
authors.affiliation: From Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis (W.B., S.D., A.T.H.); Department of Medicine, McMaster University, Hamilton, Ontario (S.J.C., S.C., J.P., J.W.E., S.Y.); Mt. Sinai School of Medicine, New York (J.L.H.); Division of Cardiology, Minneapolis Veterans Administration Medical Center, MN (S.A.); Lankenau Institute for Medical Research, Wynnewood, PA (M.D.E.); and Uppsala Clinical Research Center, Sweden (L.G.W.).
authors.forename: Janice
authors.initials: J
authors.lastname: Pogue
authors.affiliation: From Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis (W.B., S.D., A.T.H.); Department of Medicine, McMaster University, Hamilton, Ontario (S.J.C., S.C., J.P., J.W.E., S.Y.); Mt. Sinai School of Medicine, New York (J.L.H.); Division of Cardiology, Minneapolis Veterans Administration Medical Center, MN (S.A.); Lankenau Institute for Medical Research, Wynnewood, PA (M.D.E.); and Uppsala Clinical Research Center, Sweden (L.G.W.).
authors.forename: Michael D
authors.initials: MD
authors.lastname: Ezekowitz
authors.affiliation: From Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis (W.B., S.D., A.T.H.); Department of Medicine, McMaster University, Hamilton, Ontario (S.J.C., S.C., J.P., J.W.E., S.Y.); Mt. Sinai School of Medicine, New York (J.L.H.); Division of Cardiology, Minneapolis Veterans Administration Medical Center, MN (S.A.); Lankenau Institute for Medical Research, Wynnewood, PA (M.D.E.); and Uppsala Clinical Research Center, Sweden (L.G.W.).
authors.forename: John W
authors.initials: JW
authors.lastname: Eikelboom
authors.affiliation: From Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis (W.B., S.D., A.T.H.); Department of Medicine, McMaster University, Hamilton, Ontario (S.J.C., S.C., J.P., J.W.E., S.Y.); Mt. Sinai School of Medicine, New York (J.L.H.); Division of Cardiology, Minneapolis Veterans Administration Medical Center, MN (S.A.); Lankenau Institute for Medical Research, Wynnewood, PA (M.D.E.); and Uppsala Clinical Research Center, Sweden (L.G.W.).
authors.forename: Lars G
authors.initials: LG
authors.lastname: Wallentin
authors.affiliation: From Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis (W.B., S.D., A.T.H.); Department of Medicine, McMaster University, Hamilton, Ontario (S.J.C., S.C., J.P., J.W.E., S.Y.); Mt. Sinai School of Medicine, New York (J.L.H.); Division of Cardiology, Minneapolis Veterans Administration Medical Center, MN (S.A.); Lankenau Institute for Medical Research, Wynnewood, PA (M.D.E.); and Uppsala Clinical Research Center, Sweden (L.G.W.).
authors.forename: Salim
authors.initials: S
authors.lastname: Yusuf
authors.affiliation: From Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis (W.B., S.D., A.T.H.); Department of Medicine, McMaster University, Hamilton, Ontario (S.J.C., S.C., J.P., J.W.E., S.Y.); Mt. Sinai School of Medicine, New York (J.L.H.); Division of Cardiology, Minneapolis Veterans Administration Medical Center, MN (S.A.); Lankenau Institute for Medical Research, Wynnewood, PA (M.D.E.); and Uppsala Clinical Research Center, Sweden (L.G.W.). hirsc005@umn.edu.
authors.forename: Alan T
authors.initials: AT
authors.lastname: Hirsch
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001281:Atrial Fibrillation / Q000175:diagnosis* / Q000453:epidemiology* / Q000401:mortality; D004311:Double-Blind Method; D004617:Embolism / Q000175:diagnosis* / Q000453:epidemiology* / Q000401:mortality; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome
keywords: arrhythmias, cardiac; atrial fibrillation; embolism; peripheral artery disease; risk factors