TRANSESOPHAGEAL ECHOCARDIOGRAPHIC CORRELATES OF THROMBOEMBOLISM IN HIGH-RISK PATIENTS WITH NONVALVULAR ATRIAL-FIBRILLATION

Citation
M. Zabalgoitia et al., TRANSESOPHAGEAL ECHOCARDIOGRAPHIC CORRELATES OF THROMBOEMBOLISM IN HIGH-RISK PATIENTS WITH NONVALVULAR ATRIAL-FIBRILLATION, Annals of internal medicine, 128(8), 1998, pp. 639
Citations number
24
Language
INGLESE
art.tipo
Article
Categorie Soggetti
Medicine, General & Internal
Journal title
ISSN journal
0003-4819
Volume
128
Issue
8
Year of publication
1998
Database
ISI
SICI code
0003-4819(1998)128:8<639:TECOTI>2.0.ZU;2-9
Abstract
Background: Transesophageal echocardiography (TEE) visualizes potentia l sources of embolism in patients with atrial fibrillation, but the cl inical significance of TEE findings has not been prospectively establi shed. Objective: To define TEE predictors of stroke in patients with a trial fibrillation and to examine response to antithrombotic therapy. Design: Prospective correlation of TEE findings at study entry with su bsequent ischemic stroke during 1.1-year mean follow-up of participant s in a randomized trial. Setting: 18 echocardiography laboratories. Pa tients: 382 patients with atrial fibrillation at high risk for thrombo embolism. Intervention: Adjusted-dose warfarin (international normaliz ed 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 echocard iographic contrast, thrombus, and plaque on the aortic arch.Results: 2 3 ischemic strokes occurred. In patients with dense spontaneous echoca rdiographic contrast (20%), the rate of stroke was 18.2% per year with combination therapy (2.9 times the rate in patients without this find ing; 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 Z 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 compl ex aortic plaque (35%) had a fourfold increased rate of stroke compare d with plaque-free patients (P = 0.005); adjusted-dose warfarin decrea sed risk by 75% (P = 0.02). Dense spontaneous echocardiographic contra st and complex aortic plaque were independent of each other as predict ors 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 pa tients with atrial fibrillation, the pathogenesis of stroke is multifa ctorial, and warfarin seems effective for the diverse mechanisms.