Author: Sebastian Valentin Costea

University of Medicine and Pharmacy Targu Mures

Assessment of thromboembolic risk factors in atrial fibrillation.

Is transesophageal echocardiography necessary?

Atrial fibrillation is the most common cardiac arrhythmia.

Around 1% of the World’s population affected.

The most frequent treatment:

ELECTRICAL CARDIOVERSION

European Society of Cardiology Recommandations:

• If atrial fibrillation < 48h → emergent cardioversion

• If atrial fibrillation > 48h → transesophageal echocardiography(TEE) to exclude thrombi

→ 3 weeks treatment with oral anticoagulants (INR 2-3)

• After 3 weeks of treatment with oral anticoagulants → electrical cardioversion WITHOUT TEE.

Objective of the study:

To assess if electrical cardioversion non-preceded by transesophageal echocardiography is really safe for all the patients treated at least 3 weeks with oral anticoagulants.

Material and method:

-retrospective study on 96 patients with non-valvular atrial fribrillation

-data recorded:sex, age, duration of atrial fribrillation, CHADS-VASc score, atrial dimensions, blood velocities and diabetes.

-the data was analysed using MedCalc software.

Results:

After at least 3 weeks of treatment with oral anticoagulants, before cardioversion, 97.30% of the patients had INR 2-3.

97.30%

2.70%

Patient's INR

Efficient INRInefficient INR

After analysis, we discovered the following information:

Results:

21.62%

78.38%

LAA thrombosis at pa-tients treatet with oral an-

ticoagulantsLAA thrombosisNo LAA thrombosis

Unfortunately, we detected LAA thrombosis using TEE at 21.62% of the patients treated with oral anticoagulants.

Large number of patients with LAA thrombosis

Results:

Significant association between age and LAA thrombosis

Age > 65 years

3.34 higher risk for LAA thrombosis.

Variable Odds Ratio p

AGE >65 years 3.34 0.05

Results:

Also, there is a significant association between LAA thrombosis and atrial fibrillation debuted over 3 months.

Over 3 months

(Chi square test, p=0.012)

LAA thrombosis

Results:

Furthermore, CHADS-VASc < 2 is protective against LAA thrombosis.

CHADS-VASc

< 2

Protective against LAA thrombosis

Variable Odds Ratio p

CHADS-VASc < 2 0.1880 0.037

Results:

There were no significant associations between sex, atrial dimensions, diabetes and LAA thrombosis at patients treated with oral anticoagulants.

Conclusions:

As I presented earlier, 97.30% of the patients treated at least 3 weeks with oral anticoagulants had an INR between 2-3 when they were presented for cardioversion.

Because of our possibilities to monitor and effectively follow-up patients, we cannot be confident that the INR value was 2-3 over the entire period of 3 weeks, or more.

Conclusions:

A high percentage (21.62%) of the patients included in the study had LAA thrombosis and the majority of them belong to the risk categories.

We assume that other factors could generate such a high number, like patient’s compliance for treatment.

Conclusions:

If it’s not possible for all patients, at least consider performing TEE to patients with suspicious anticoagulant treatment, or to those belonging the following categories:

Age > 65

years

CHADS-VASc

≥ 2

Atrial Fibrillation > 3 months