Importance of atrial fibrillation as a cause of thromboembolism Review article
Article Sidebar
Main Article Content
Abstract
Atrial fibrillation (AF) is not such a benign arrhythmia as it was considered for many years. It cause severe clinical complications and most important are heart failure and systemic embolism, particularly stroke. Despite clinically manifested stroke more frequent are episodes of silent cerebral ischemia which can deteriorate patient’s quality of life.
The incidence of systemic embolisation due to atrial fibrillation depends of arrhythmia etiology (rheumatic vs nonrheumatic), duration of arrhythmia and type of atrial fibrillation (paroxysmal vs chronic). Despite of of method used, reversion of atrial fibrillation to sinus rhythm itself is also considered as a potential risk factor of stroke.
The mechanisms explaining systemic embolisation due to atrial fibrillation are connected with arrhythmia per se and also can be a consequence of sinus rhythm restoration.
Echocardiography is the valuable method of recognition of atrial fibrillation etiology. Transoesophageal application of echocardiography gives additional benefits because allows to find embolic material in cardiac caves. It helps also to elucidate pathomechanism of ischemic episodes and recognizes important factors used to stratification of stroke risk. Lastly, it is very useful for management and individualization treatment in particular patients.
In patients with atrial fibrillation there are several clinical risk factors of stroke development including: previous stroke or TIA, hypertension, diabetes, heart failure and age above 75 years. In stratification of stroke risk very helpful are some echocardiographic parameters as: dysfunction of left ventricle, intensive spontaneous echocardiographic contrast, left atrium appendage flow velocity below <20 cm/s, complex atherosclerotic plaques in aorta.
Severe risk of systemic embolisation coexisting with atrial fibrillation needs to be reduced. The most important is elimination of arrhythmia inducing causes. In case when it is impossible prevention actions must be introduced. This can be achieved by adequate anticoagulation treatment as well as plenty novel methods of cardiac surgery and invasive cardiology procedures.
Downloads
Article Details
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Copyright: © Medical Education sp. z o.o. This is an Open Access article distributed under the terms of the Attribution-NonCommercial 4.0 International (CC BY-NC 4.0). License (https://creativecommons.org/licenses/by-nc/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
Address reprint requests to: Medical Education, Marcin Kuźma (marcin.kuzma@mededu.pl)
References
2. Kannel W.B., Abbott R.D., Savage D.D. et al.: Epidemiological features of chronic atrial fibrillation. N. Engl. J. Med. 1982; 306: 1018-1022.
3. Petersen P., Boysen G., Godtfredsen J. et al.: Placebo controlled randomized trial of warfarin and aspirin for prevention of thromboembolic complication in chronic atrial fibrillation. The Copenhagen AFASAK Study. Lancet 1989; 1: 175-178.
4. The Stroke Prevention in Atrial Fibrillation Study group Investigators: Stroke prevention in atrial fibrillation study: final results. Circulation 1991; 84: 527-539.
5. Stroke Prevention in Atrial Fibrillation Investigators. Warfarin versus aspirin for prevention of thromboembolism in atrial fibrillation: Stroke Prevention in Atrial Fibrillation II Study. Lancet 1994; 343: 687-691.
6. Connolly S.J.: Canadian Atrial Fibrillation Anticoagulation (CAFA) Study. J. Am. Coll. Cardiol. 1991; 18: 349-355.
7. The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators: The effect of low dose warfarin on the the risk of stroke in patients with nonrheumatic atrial fibrillation. N. Engl. J. Med. 1990; 323: 1505-1511.
8. Radecliffe P.J., Wilcock G.K.: Cerebrovascular disease in dementia. The importance of atrial fibrillation. Postgrad. Med. J. 1985; 61: 201-204.
9. Ezekowitz M.D., James K.E., Nazarian S.M.: Silent cerebral infarction in patients with nonrheumatic atrial fibrillation. Circulation 1995; 92: 2178-2182.
10. Ezekowitz M.P., Wilson D.A., Smith E.O. et al.: Comparison of Indium 111 plateled scintigraphy and two dimensional echocardiography in the diagnosisof left ventricular thrombi. N. Engl. J. Med. 1982; 306: 1509-13.
11. Kempster P.A., Gerraty R.P., Gates P.C.: Asymptomatic cerebral infarction in patients with chronic atrial fibrillation. Stroke 1988; 19: 955-957.
12. Petersen P., Madsen E.B., Brun B. et al.: Silent cerebral infarction in patients with chronic atrial fibrillation. Stroke 1987; 18: 1098-1100.
13. Kopecky S.L., Gersh B.J., Mc Goon M.D. et al.: The natural history of lone atrial fibrillation a population based study over three decades. N. Engl. J. Med. 1987; 16: 669-674.
14. Brand F.N., Abbott R.D., Kannely W.B. et al.: Characteristic and prognosis of lone atrial fibrillation: 30-year follow-up in the Framingham study. JAMA 1985; 254: 3449-3453.
15. Kelly R.E., Berger J.R., Alter M. et al.: Cerebral ischemia and atrial fibrillation: Prospective Study. Neurology 1984; 34: 1285-1291.
16. Sherman D.G., Goldman L., Whiting R.B. et al.: Risk of thromboembolism in patients with atrial fibrillation. Arch. Neur. 1984; 41: 708-710.
17. Takahashi N., Seki A., Imataka K.: Clinical features of paroxysmal atrial fibrillation: An observation of 94 patients. Jpn. Heart J. 1981; 22: 143-149.
18. Petersen P., Godtfredsen J.: Embolic complications in paroxysmal atrial fibrillation. Stroke 1986; 17: 622-625.
19. Wiener J., Hafner R., Nicolai M. et al.: Clinical and echocardiographic correlates of systemic embolization in nonrheumatic atrial fibrillation. Am. J. Cardiol. 1987; 59: 177-179.
20. Kannel W.B., Abbott R.D., Savage D.D. et al.: Coronary heart disease and atrial fibrillation: The Framingham study. Am. Heart J. 1983; 106: 393-396.
21. Darling R.C., Austen W.G., Linton R.R.: Arterial embolism. Surg. Gynecol. Obstet. 1987; 124: 106-114.
22. Sage J.I., van Uitert R.L.: Risk of reccurent stroke in patients with atrial fibrillation and nonvalvular heart disease. Stroke 1983; 14: 537-540.
23. European Atrial Fibrillation Trial Study Group. Secondary prevention in non-rheumatic atrial fibrillation after ischaemic attack or minor stroke. Lancet 1993; 342: 1255-1262.
24. Fuster V., Ryden L.E., Asinger R.W. et al.: ACC/AHA/ESC 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 or the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology. Eur. Heart J. 2001; 22: 1852-1923.
25. The Stroke Prevention in Atrial Fibrillation Investigators. Predictors of thromboembolism in atrial fibrillation. II. Echocardiographic features of patients at risk. Ann. Intern. Med. 1992; 116: 6-12.
26. Kamp O., Verhorst P.M.J., Visser A.: Value of left atrial appendage flow velocities in patients with nonrheumatic atrial fibrillation and systemic embolism. W: Atrial Fibrillation a Treatable Disease? Kingma J.H. i wsp. (red.). Kluwer Academic Publisher, Holandia 1992: 259-269.
27. Fatkin D., Kelly R.P., Feneley M.P.: Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast and thromboembolic risk in vivo. J. Am. Coll. Cardiol. 1994; 23: 961-969.
28. Kumagei K., Fukunami M., Okmori M. et al.: Increased intravascular clotting in patients with atrial fibrillation. J. Am. Coll. Cardiol. 1990; 16: 377-380.
29. Petersen P., Kastrup J., Videbaek R.: Cerebral blood flow before and after cardioversion of atrial fibrillation. J. Cereb. Blood Flow Metab. 1989; 9: 422-425.
30. Lip G.Y.H., Lowe G.D.O., Rumley A.: Increased markers of thrombogenesis in chronic atrial fibrillation: effects of warfarin treatment. Br. Heart J. 1995; 73: 527-533.
31. Goldmann M.J.: The management of chronic atrial fibrillation. Prog. Cardiovasc. Dis. 1960; 2: 465-79.
32. Archer S.L., James K.E., Kvernan L.P. et al.: Role of transesophageal echocardiography in the detection of left atrial thrombus in patients with chronic nonrheumatic atrial fibrillation. Am. Heart J. 1995; 130: 287-95.
33. Black I.W., Fatkin D., Walsh W.F. et al.: Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation: a multicenter study. Circulation 1994; 89; 2509-13.
34. Grimm R.A., Stewart W.J., Maloney J.D. et al.: Impact of electrical cardioversion for atrial fibrillation on left appendage function and spontaneous echo contrast: chracterisation by simultaneous transesophageal echocardiography. J. Am. Coll. Cardiol. 1993; 22: 1359-66.
35. Come P.C., Riley M.F., Markis J.E. et al.: Limitations of echocardiographic techniques in evaluation of left atrial masses. Am. J. Cardiol. 1981; 48; 947-53.
36. Aschenberg W., Schluter M., Kremer P. et al.: Transesophageal two-dimensional echocardiography for the detection of left atrial appendage thrombus. J. Am. Coll. Cardiol. 1986; 7: 163-166.
37. Daniel W.G., Nikutta P., Schroder E. et al.: Transesophageal echocardiography detection of left atrial appendage thrombi in patients with unexplained arterial embolism (abstract). Circulation 1986; 74 II-381.
38. Malone S.A., Polac R.T., Imus R.L. et al.: Prevalence of left atrial thrombi in symptomatic versus asymptomatic patients with nonvalvular atrial fibrillation (Abstract). Circulation 1989; 80: II-1.
39. Iuchi A., Oki T., Fukuda N. et al.: Changes in transmitral and pulmonary venosus flow velocity patterns after cardioversion of atrial fibrillation. Am. Heart J. 1996; 135: 270-275.
40. Fatkin D., Kuchar D.L., Thorburn C.W. et al.: Transesophageal echocardiography before and during direct current cardioversion of atrial fibrillation: evidence for „atrial stunning” as a mechanism of thromboembolic complication. J. Am. Coll. Cardiol. 1994; 23: 307-316.
41. Mitush R., Garbe M., Schmucher G. et al.: Relation of left atrial appendage function to the duration and reversibility of nonvalvular atrial fibrillation. Am. J. Cardiol. 1995; 75: 944-947.
42. Manning W.J., Silverman D., Gordon S.P.F. et al.: Cardioversion from atrial fibrillation without prolonged anticoagulation with use of transesophageal echocardiography to exclude the presence of atrial thrombi. N. Engl. Med. 1993; 328: 750-5.
43. Stratton J.R., Ritchie J.L.: 111 In plateled imaging of left ventricular thrombi: predictive value for systemic emboli. Circulation 1990; 81: 1182-9.
44. Vandenberg B.F., Seabold J.E., Conrad G.R. et al.: 111 In-labeled plateled scintigraphy and two dimensional echocardiography of left atrial appendage thrombi: studies in a new canine model. Circulation 1988; 78: 1040-6.
45. Ezekowitz M.D., Bridges S.I., James K.E. et al.: The Veterans Affairs Stroke Prevention in Nonrheumatic Atrial Fibrillation investigators: Warfarin in the prevention of stroke associated with nonrheumatic atrial fibrillation. N. Engl. J. Med. 1992; 327: 1406-1412.
46. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch. Intern. Med. 1994; 154: 1449-57.
47. Fuster V., Ryden L.E., Cannom D.S. 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. Eur. Heart J. 2006; 27: 1979-2030.
48. Wysokiński A., Zapolski T.: Migotanie przedsionków. Skrzepliny i spontaniczny echokardiograficzny kontrast w uszku lewego przedsionka. Modyfikacja w toku leczenia przeciwzakrzepowowego. Kardiol. Pol. 2000; 52: 259-266.
49. Orsinelli D.A., Pearson A.C.: Usefulness of transesophageal echocardiography to screen for left atrial thrombus before elective cardioversion for atrial fibrillation. Am. J. Cardiol. 1993; 72: 1337-39.
50. Black I.W., Hopkins A.P., Lee L.C. et al.: Evaluation of transesophageal echocardiography before cardioversion of atrial fibrillation and flutter in nonanticoagulated patients. Am. Heart J. 1993; 126: 375-381.
51. Sudlow M., Thomson R., Thwaites B. et al.: Prevalance of atrial fibrillation and eligibility for anticoagulants in the community. Lancet 1998; 352: 1167-1171.
52. Katz E.S., Tsiamtsiouris T., Applebaum R.M. et al.: Surgical left atrail appendage ligation is frequently incomplete: a transesophageal echocardiographic study. J. Am. Coll. Cardiol. 2000; 36: 468-471.