Which method of left atrium size quantification is the most accurate to recognize thromboembolic risk in patients with non-valvular atrial fibrillation?
Tóm tắt
Left atrial (LA) size is a predictor of cardiovascular outcomes in patients in sinus rhythm, whereas conflicting results have been found in atrial fibrillation (AF). This study aims to: (1) Evaluate the accuracy of LA size to identify surrogate markers of an increased thromboembolic risk in patients with AF; (2) Assess the best method to evaluate LA size in this setting. Cross-sectional study enrolling 500 consecutive patients undergoing transthoracic and transesophageal echocardiography evaluation during a non-valvular AF episode. LA size was measured on transthoracic echocardiography using several methods: anteroposterior diameter, area in four-chamber view, and volumes by the ellipsoid, single- and biplane area-length formulas. Surrogate markers of stroke were evaluated by transesophageal echocardiography: LA appendage (LAA) thrombus, LAA low flow velocities, dense spontaneous echocardiographic contrast and LA abnormality. Except for non-indexed anteroposterior diameter, increased LA size quantified by all the other methods showed a moderate to high discriminatory power to identify all the surrogate markers of stroke. A higher accuracy was observed for indexed LA area in four-chamber view (LAA thrombus: AUC = 0.708, CI95% 0.644- 0.772, p<0.001; LAA low flow velocities: AUC = 0.733, CI95% 0.674- 0.793, p<0.001; dense spontaneous echocardiographic contrast: AUC = 0.693, CI95% 0.638- 0.748, p<0.001; LA abnormality: AUC = 0.705, CI95% 0.654-0.755, p<0.001), indexed single-plane area-length volume (LAA thrombus: AUC = 0.701, CI95% 0.633-0.770, p<0.001; LAA low flow velocities: AUC = 0.726, CI95% 0.660-0.792, p<0.001; dense spontaneous echocardiographic contrast: AUC = 0.673, CI95% 0.611-0.736, p<0.001; LA abnormality: AUC = 0.687, CI95% 0.629-0.744, p<0.001), and indexed biplane area-length volume (LAA thrombus: AUC = 0.707, CI95% 0.626-0.788, p<0.001; LAA low flow velocities: AUC = 0.737, CI95% 0.664-0.810, p<0.001; dense spontaneous echocardiographic contrast: AUC = 0.651, CI95% 0.578-0.724, p<0.001; LA abnormality: AUC = 0.683, CI95% 0.617-0.749, p<0.001), without significant difference between them. Indexed LA area in four-chamber view and indexed area-length volumes also were independent predictors of surrogate markers of stroke. Left atrium enlargement is associated with an increased prevalence of surrogate markers of stroke in patients with non-valvular AF. Indexed LA area in four-chamber view and indexed area-length volumes displayed the strongest association.
Tài liệu tham khảo
Benjamin EJ, D’Agostino RB, Belanger AJ, Wolf PA, Levy D: Left atrial size and the risk of stroke and death. The Framingham Heart Study. Circulation. 1995, 92: 835-841.
Tsang T, Barnes M, Bailey K, Leibson CL, Montgomery SC, Takemoto Y, Diamond PM, Marra MA, Gersh BJ, Wiebers DO, Petty GW, Seward JB: Left atrial volume: important risk marker of incident atrial fibrillation in 1655 older men and women. Mayo Clin Proc. 2001, 76: 467-475.
Barnes ME, Miyasaka Y, Seward JB, Gersh BJ, Rosales AG, Bailey KR, Petty GW, Wiebers DO, Tsang TS: Left atrial volume in the prediction of first ischemic stroke in an elderly cohort without atrial fibrillation. Mayo Clin Proc. 2004, 79: 1008-1014.
Tsang TS, Gersh BJ, Appleton CP, Tajik AJ, Barnes ME, Bailey KR, Oh JK, Leibson C, Montgomery SC, Seward JB: Left ventricular diastolic dysfunction as a predictor of the first diagnosed nonvalvular atrial fibrillation in 840 elderly men and women. J Am Coll Cardiol. 2002, 40: 1636-1644.
Tsang TS, Barnes ME, Gersh BJ, Bailey KR, Seward JB: Risks for atrial fibrillation and congestive heart failure in patients ≥ 65 years of age with abnormal left ventricular diastolic relaxation. Am J Cardiol. 2004, 93: 54-58.
Aronow WS, Gutstein H, Hsieh FY: Risk factors for thromboembolic stroke in elderly patients with chronic atrial fibrillation. Am J Cardiol. 1989, 63: 366-367.
Aronow WS, Ahn C, Kronzon I, Gutstein H: Risk factors for new thromboembolic stroke in patients > or = 62 years of age with chronic atrial fibrillation. Am J Cardiol. 1998, 82: 119-121.
Osranek M, Bursi F, Bailey KR, Grossardt BR, Brown RD, Kopecky SL, Tsang TS, Seward JB: Left atrial volume predicts cardiovascular events in patients originally diagnosed with lone atrial fibrillation: three-decade follow-up. Eur Heart J. 2005, 26: 2556-2561.
Caplan LR, D'Cruz I, Hier DB, Reddy H, Shah S: Atrial size, atrial fibrillation and stroke. Ann Neurol. 1986, 19: 158-161.
Vaziri SM, Larson MG, Benjamin EJ, Levy D: Echocardiographic predictors of nonrheumatic atrial fibrillation. The Framingham Heart Study. Circulation. 1994, 89: 724-730.
Leung DY, Boyd A, Arnold H, Chi C, Thomas L: Echocardiographic evaluation of left atrial size and function: current understanding, pathophysiologic correlates, and prognostic implications. Am Heart J. 2008, 156: 1056-1064.
Tsang TS, Abhayaratna WP, Barnes ME, Miyasaka Y, Gersh BJ, Bailey KR, Cha SS, Seward JB: Prediction of cardiovascular outcomes with left atrial size. Is volume superior to area or diameter?. J Am Coll Cardiol. 2006, 47: 1018-1023.
Russo C, Hahn RT, Jin Z, Homma S, Sacco RL, Di Tullio MR: Comparison of echocardiographic single- vs biplane method in the assessment of left atrial volume and validation by real time three-dimensional echocardiography. J Am Soc Echocardiogr. 2010, 23 (9): 954-960.
Abhayaratna WP, Seward JB, Appleton CP, Douglas PS, Oh JK, Tajik AJ, Tsang TSM: Left atrial size: physiologic determinants and clinical applications. J Am Coll Cardiol. 2006, 47: 2357-2363.
Badano LP, Pezzutto N, Marinigh R, Cinello M, Nucifora G, Pavoni D, Gianfagna P, Fioretti PM: How many patients would be misclassified using M-mode and two-dimensional estimates of left atrial size instead of left atrial volume? A three-dimensional echocardiographic study. J Cardiovasc Med. 9: 476-484.
Maddukuri PV, Vieira ML, DeCastro S, Maron MS, Kuvin JT, Patel AR, Pandian NG: What is the best approach for the assessment of left atrial size? Comparison of various unidimensional and Two-dimensional parameters with three-dimensional echocardiographically determined left atrial volume. J Am Soc Echocardiogr. 2006, 19: 1026-1032.
Khankirawatana B, Khankirawatana S, Porter T: How should left atrial size be reported? Comparative assessment with use of multiple echocardiographic methods. Am Heart J. 2004, 147: 369-374.
Wang Y, Gutman JM, Heilbron D, Wahr D, Schiller NB: Atrial volume in a normal adult population by two-dimensional echocardiography. Chest. 1984, 86: 595-601.
Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise J, Solomon S, Spencer KT, Sutton MSJ, Stewart W: Recommendations for chamber quantification. Eur J Echocardiogr. 2006, 7: 79-108.
Zabalgoitia M, Halperin JL, Pearce LA, Blackshear JL, Asinger RW, Hart RG: Stroke Prevention in Atrial Fibrillation III Investigators. Transesophageal echocardiographic correlates of clinical risk of thromboembolism in nonvalvular atrial fibrillation. J Am Coll Cardiol. 1998, 31: 1622-1626.
Leung DY, Black IW, Cranney GB, Hopkins AP, Walsh WF: Prognostic implications of left atrial spontaneous echo contrast in nonvalvular atrial fibrillation. J Am Coll Cardiol. 1994, 24: 755-762.
Albers GW, Dalen JE, Laupacis A, Manning WJ, Petersen P, Singer DE: Antithrombotic therapy in atrial fibrillation. The Sixth ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2001, 119: 194S-206S.
Lip GYH, Lane D, van Walraven C, Hart RG: Additive role of plasma von Willebrand Factor levels to clinical factors for risk stratification in patients with atrial fibrillation. Stroke. 2006, 37: 2294-2300.
The Stroke Prevention in Atrial Fibrillation Investigators Committee on Echocardiography: Transesophageal echocardiographic correlates of thromboembolism in high-risk patients with nonvalvular atrial fibrillation. Ann Intern Med. 1998, 128: 639-647.
Providência R, Trigo J, Paiva L, Barra S: The role of echocardiography in thromboembolic risk assessment of patients with nonvalvular atrial fibrillation. J Am Soc Echocardiogr. 2013, 26: 801-812.
Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ: Validation of clinical classification schemes for predicting stroke: results from the National Registry of atrial fibrillation. JAMA. 2001, 285: 2864-2870.
Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ: Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010, 137: 263-272.
Beppu S, Park YD, Sakakibara H, Nagata S, Nimura Y: Clinical features of intracardiac thrombosis based on echocardiographic observation. Jpn Cite J. 1984, 48: 75-82.
Beppu S, Nimura Y, Sakakihara H, Nagata S, Park YD, Izumi S: Smoke-like echo in the left atrial cavity in mitral valve disease: its features and significance. J Am Coll Cardiol. 1985, 6: 744-749.
Fatkin D, Kelly RP, Feneley MP: Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast and thromboembolic risk in vivo. J Am Coll Cardiol. 1994, 23: 961-969.
Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, Gelder ICV, Al-Attar N, Hindricks G, Prendergast B, Heidbuchel H, Alfieri O, Angelini A, Atar D, Colonna P, De Caterina R, De Sutter J, Goette A, Gorenek B, Heldal M, Hohloser SH, Kolh P, Le Heuzey JY, Ponikowski P, Rutten FH: Guidelines for the management of atrial fibrillation: the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010, 31: 2369-2429.
Wann LS, Curtis AB, Ellenbogen KA, Estes M, Ezekowitz MD, Jackman WM, January CT, Lowe JE, Page RL, Slotwiner DJ, Stevenson WG, Tracy CM: 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (update on dabigatran): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011, 123: 1144-1150.
Ayirala S, Kumar S, O’Sullivan DM, Silverman DI: Echocardiographic predictors of left atrial appendage thrombus formation. J Am Soc Echocardiogr. 2011, 24: 499-505.
Providência R, Botelho A, Trigo J, Quintal N, Nascimento J, Mota P, Leitão-Marques A: Possible refinement of clinical thromboembolism assessment in patients with atrial fibrillation using echocardiographic parameters. Europace. 2012, 14: 36-45.