Wobo Bekwelem1, Stuart J Connolly1, Jonathan L Halperin1, Selcuk Adabag1, Sue Duval1, Susan Chrolavicius1, Janice Pogue1, Michael D Ezekowitz1, John W Eikelboom1, Lars G Wallentin1, Salim Yusuf1, Alan T Hirsch2. 1. 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.). 2. 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.
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. METHODS AND 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.
RCT Entities:
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. METHODS AND 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: Emelia J Benjamin; Michael J Blaha; Stephanie E Chiuve; Mary Cushman; Sandeep R Das; Rajat Deo; Sarah D de Ferranti; James Floyd; Myriam Fornage; Cathleen Gillespie; Carmen R Isasi; Monik C Jiménez; Lori Chaffin Jordan; Suzanne E Judd; Daniel Lackland; Judith H Lichtman; Lynda Lisabeth; Simin Liu; Chris T Longenecker; Rachel H Mackey; Kunihiro Matsushita; Dariush Mozaffarian; Michael E Mussolino; Khurram Nasir; Robert W Neumar; Latha Palaniappan; Dilip K Pandey; Ravi R Thiagarajan; Mathew J Reeves; Matthew Ritchey; Carlos J Rodriguez; Gregory A Roth; Wayne D Rosamond; Comilla Sasson; Amytis Towfighi; Connie W Tsao; Melanie B Turner; Salim S Virani; Jenifer H Voeks; Joshua Z Willey; John T Wilkins; Jason Hy Wu; Heather M Alger; Sally S Wong; Paul Muntner Journal: Circulation Date: 2017-01-25 Impact factor: 29.690
Authors: Marie D Gerhard-Herman; Heather L Gornik; Coletta Barrett; Neal R Barshes; Matthew A Corriere; Douglas E Drachman; Lee A Fleisher; Francis Gerry R Fowkes; Naomi M Hamburg; Scott Kinlay; Robert Lookstein; Sanjay Misra; Leila Mureebe; Jeffrey W Olin; Rajan A G Patel; Judith G Regensteiner; Andres Schanzer; Mehdi H Shishehbor; Kerry J Stewart; Diane Treat-Jacobson; M Eileen Walsh Journal: Circulation Date: 2016-11-13 Impact factor: 29.690
Authors: Pratik S Velangi; Christopher Choo; Ko-Hsuan A Chen; Felipe Kazmirczak; Prabhjot S Nijjar; Afshin Farzaneh-Far; Osama Okasha; Mehmet Akçakaya; Jonathan W Weinsaft; Chetan Shenoy Journal: Circ Cardiovasc Imaging Date: 2019-11-11 Impact factor: 7.792
Authors: Ryan Orgel; Daniel Wojdyla; David Huberman; Jonathan L Halperin; Günter Breithardt; Daniel E Singer; Keith A A Fox; Graeme J Hankey; Kenneth W Mahaffey; W Schuyler Jones; Manesh R Patel Journal: Circ Cardiovasc Qual Outcomes Date: 2017-05