ECHO 2013 / Advanced TEE Clinical Decision Making in Cryptogenic Stroke and Atrial Fibrillation

Is CHADS2 score all we need to know?

•In patients with CHADS2 score 0-1, annual stroke rate is still quite high (1.9% to 2.8%)

•In 295 patients with score 0 or 1, prevalence of LA thrombus by TEE was 3% and prevalence of dense spontaneous echo-contrast was 8%

•Therefore, 11% of patients with low score had an indication for anticoagulation when TEE was performed

Kleeman et al, Eur J Echocardiogr 2009;10:383-8

Left Atrial Appendage Thrombus

•Present in over 20% of patients with atrial fibrillation undergoing TEE

•More frequent in chronic atrial fibrillation (27%), but also present with acute (< 3 days) onset (14%)

•In patients with recent embolic events, no difference in prevalence between chronic and acute atrial fibrillation (23% vs. 21%)

Stoddard et al., J Am Coll Cardiol 1995, 25(2):452-9

Spontaneous Echo-contrast (SEC)

•Present in over 50% of patients with atrial fibrillation undergoing TEE

•Associated with 12% embolic event rate per year (vs. 3% in patients with atrial fibrillation without SEC)

•Survival improved by warfarin treatment

Leung et al, J Am Coll Cardiol 1994;24:755-62

Handke et al, Am J Cardiol 2005;96:1342-4

• In SPAF III, the presence of SEC almost tripled the risk of stroke

SPAF Investigators, Ann Int Med 1998;128:639-47

• With LA thrombus or SEC, 3-fold increase in 5-year mortality

Kleeman et al et al, Eur J Echocardiogr 2009;10:383-8

Atrial Fibrillation and Aortic Arch Plaques

•In the SPAF III trial, 382 patients underwent TEE, 35% had complex aortic plaques

•Among multiple possible predictors of events, only SEC and complex arch plaques were found to be independently associated with recurrent vascular events

•Adjusted-dose warfarin treatment decreased the event rates by 75% compared with fixed-dose warfarin plus aspirin (4.0% vs. 15.8%; p=0.02)

•In patients without complex arch plaques, event rate was low (1.1% to 1.2% per year) regardless of treatment

SPAF Investigators, Ann Int Med 1998;128:639-47