Jung Myung Lee1, Jin-Bae Kim2, Jae-Sun Uhm3, Hui-Nam Pak3, Moon-Hyoung Lee3, Boyoung Joung4. 1. Department of Medicine, Graduate School, Kyung Hee University, Seoul, Republic of Korea. 2. Division of Cardiology, Department of Internal Medicine, Kyung Hee University Medical College, Seoul, Republic of Korea. 3. Division of Cardiology, Department of Internal Medicine, Yonsei University Medical College, Seoul, Republic of Korea. 4. Division of Cardiology, Department of Internal Medicine, Yonsei University Medical College, Seoul, Republic of Korea. Electronic address: cby6908@yuhs.ac.
Abstract
BACKGROUND: Strokes occur in some patients with atrial fibrillation (AF), even when the CHA2DS2-VASc (congestive heart failure, hypertension, age >75 years, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age>65 years, female sex) score is low. OBJECTIVE: We sought to determine the factors defining the residual stroke risk in patients with AF and low CHA2DS2-VASc scores, with a particular focus on the hemodynamics and geometry of the left atrial appendage (LAA). METHODS: From February 1, 2008 to December 31, 2012, 66 consecutive patients with nonvalvular AF and a CHA2DS2-VASc score of 0 or 1 (except a point for the female sex) were enrolled. All patients were admitted with a diagnosis of acute ischemic stroke. The control group consisted of patients with nonvalvular AF without a history of stroke. RESULTS: The LAA orifice area was larger (4.35 ± 1.51 cm2 vs 2.83 ± 0.9 cm2; P < .001) and the LAA flow velocity was lower (41.9 ± 22.7 cm/s vs 54.4 ± 19.9 cm/s; P < .001) in the stroke group than in the control group. Low LAA flow velocity (<40 cm/s) and large LAA orifice area (>4 cm2) were independent predictors of stroke. Patients with an LAA flow velocity of <40 cm/s and an LAA orifice of >4.0 cm2 had a markedly higher odds ratio (odds ratio 10.9; 95% confidence interval 3.0-40.0; P < .001) of stroke than did those with preserved LAA flow velocity and smaller LAA orifice. CONCLUSION: Even in patients with low CHA2DS2-VASc scores, the presence of both decreased LAA flow velocity and increased LAA orifice size was associated with a high odds ratio of stroke. Future large prospective studies are needed to assess whether these patients should receive anticoagulants.
BACKGROUND:Strokes occur in some patients with atrial fibrillation (AF), even when the CHA2DS2-VASc (congestive heart failure, hypertension, age >75 years, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age>65 years, female sex) score is low. OBJECTIVE: We sought to determine the factors defining the residual stroke risk in patients with AF and low CHA2DS2-VASc scores, with a particular focus on the hemodynamics and geometry of the left atrial appendage (LAA). METHODS: From February 1, 2008 to December 31, 2012, 66 consecutive patients with nonvalvular AF and a CHA2DS2-VASc score of 0 or 1 (except a point for the female sex) were enrolled. All patients were admitted with a diagnosis of acute ischemic stroke. The control group consisted of patients with nonvalvular AF without a history of stroke. RESULTS: The LAA orifice area was larger (4.35 ± 1.51 cm2 vs 2.83 ± 0.9 cm2; P < .001) and the LAA flow velocity was lower (41.9 ± 22.7 cm/s vs 54.4 ± 19.9 cm/s; P < .001) in the stroke group than in the control group. Low LAA flow velocity (<40 cm/s) and large LAA orifice area (>4 cm2) were independent predictors of stroke. Patients with an LAA flow velocity of <40 cm/s and an LAA orifice of >4.0 cm2 had a markedly higher odds ratio (odds ratio 10.9; 95% confidence interval 3.0-40.0; P < .001) of stroke than did those with preserved LAA flow velocity and smaller LAA orifice. CONCLUSION: Even in patients with low CHA2DS2-VASc scores, the presence of both decreased LAA flow velocity and increased LAA orifice size was associated with a high odds ratio of stroke. Future large prospective studies are needed to assess whether these patients should receive anticoagulants.
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