Abstract
Atrial fibrillation is the most common arrhythmia and its prevalence is expected to further increase. Patients with atrial fibrillation have an increased risk of stroke (fivefold increased risk), heart failure, and death. In patients with non-valvular atrial fibrillation, the most recent guidelines recommend the use of the CHA2DS2-VASc (congestive heart failure, arterial hypertension, age > 75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65–74 years, sex category) scoring system to identify those who may benefit from oral anticoagulant treatment. Guidelines recommend initiation of oral anticoagulation with vitamin K antagonists or direct oral anticoagulants in men with a score ≥ 2 and in women with a score ≥ 3, while oral anticoagulation in individuals with a score of 0 is not recommended. Accordingly, men with CHA2DS2VASc score = 1 (and women with CHA2DS2VASc = 2) represent a grey zone where guidelines do not provide a definite oral anticoagulant indication. Implementation of risk stratification with transthoracic echocardiography could be extremely useful. Both prospective and observational studies using transthoracic echocardiography prediction of events and studies utilizing transesophageal echocardiographic parameters as surrogate markers of thromboembolic events make sustainable the hypothesis that echocardiography could improve thromboembolism prediction in non-valvular atrial fibrillation. However, because of some controversial results of different studies, determination of the best echocardiographic parameter predicting thromboembolic events in atrial fibrillation remains uncertain. The combination of left atrial enlargement with left atrial function (in particular assessing left atrial strain) appears to be very valuable, but needs to be confirmed in large-scale multi-center trials.
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Kishore A, Vail A, Majid A, Majid A, Dawson J, Lees KR, Tyrrell PJ, Smith CJ (2014) Detection of atrial fibrillation after ischemic stroke or transient ischemic attack: a systematic review and meta-analysis. Stroke 45:520–526
Wolf PA, Abbott RD, Kannel WB (1991) Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 22:983–988
Hart RG, Pearce LA, Aguilar MI (2007) Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 146:857–867
Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, ESC Scientific Document Group (2016) 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 37:2893–2962
Chao TF, Liu CJ, Wang KL, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Chen TJ, Lip GY, Chen SA (2015) Should atrial fibrillation patients with 1 additional risk factor of the CHA2DS2-VASc score (beyond sex) receive oral anticoagulation? J Am Coll Cardiol 65:635–642
Olesen JB, Lip GY, Hansen ML, Hansen PR, Tolstrup JS, Lindhardsen J, Selmer C, Ahlehoff O, Olsen AM, Gislason GH, Torp-Pedersen C (2011) Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study. BMJ 342:d124
Olesen JB, Torp-Pedersen C, Hansen ML, Lip GY (2012) The value of the CHA2DS2-VASc score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS2 score 0–1: a nationwide cohort study. Thromb Haemost 107:1172–1179
Sulzgruber P, Wassmann S, Semb AG, Doehner W, Widimsky P, Gremmel T, Kaski JC, Savarese G, Rosano GMC, Borghi C, Kjeldsen K, Torp-Pedersen C, Schmidt TA, Lewis BS, Drexel H, Tamargo J, Atar D, Agewall S, Niessner A (2019) Oral anticoagulation in patients with non-valvular atrial fibrillation and a CHA2DS2-VASc score of 1: a current opinion of the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy and European Society of Cardiology Council on Stroke. Eur Heart J Cardiovasc Pharmacother 5:171–180
Maheshwari A, Norby FL, Roetker NS, Soliman EZ, Koene RJ, Rooney MR, O'Neal WT, Shah AM, Claggett BL, Solomon SD, Alonso A, Gottesman RF, Heckbert SR, Chen LY (2019) Refining prediction of atrial fibrillation-related stroke using the P2-CHA2DS2-VASc score. Circulation 139:180–191
Donal E, Lip GY, Galderisi M, Goette A, Shah D, Marwan M, Lederlin M, Mondillo S, Edvardsen T, Sitges M, Grapsa J, Garbi M, Senior R, Gimelli A, Potpara TS, Van Gelder IC, Gorenek B, Mabo P, Lancellotti P, Kuck KH, Popescu BA, Hindricks G, Habib G, Cardim NM, Cosyns B, Delgado V, Haugaa KH, Muraru D, Nieman K, Boriani G, Cohen A (2016) EACVI/EHRA Expert Consensus Document on the role of multi-modality imaging for the evaluation of patients with atrial fibrillation. Eur Heart J Cardiovasc Imaging 17:355–383
Proietti M, Marra AM, Tassone EJ, De Vuono S, Corrao S, Gobbi P, Perticone F, Corazza GR, Basili S, Lip GY, Violi F, Raparelli V, ARAPACIS Study Investigators; GIS Group (2015) Frequency of left ventricular hypertrophy in non-valvular atrial fibrillation. Am J Cardiol 116:877–882
Bikkina M, Levy D, Evans JC, Larson MG, Benjamin EJ, Wolf PA, Castelli WP (1984) Left ventricular mass and risk of stroke in an elderly cohort. The Framingham Heart Study. JAMA 272:33–36
Tezuka Y, Iguchi M, Hamatani Y, Ogawa H, Esato M, Tsuji H, Wada H, Hasegawa K, Abe M, Lip GYH, Akao M, Fushimi AF (2020) Registry investigators. Association between relative wall thickness of left ventricle and incidence of thromboembolism in patients with non-valvular atrial fibrillation: the Fushimi AF Registry. Eur Heart J Qual Care Clin Outcomes. https://doi.org/10.1093/ehjqcco/qcaa003
Gottdiener JS, Livengood SV, Meyer PS, Chase GA (1995) Should echocardiography be performed to assess effects of antihypertensive therapy? Test-retest reliability of echocardiography for measurement of left ventricular mass and function. J Am Coll Cardiol 25:424–430
Ho JE, Lyass A, Lee D, Vasan RS, Kannel WB, Larson MG, Levy D (2013) Predictors of new-onset heart failure: differences in preserved versus reduced ejection fraction. Circ Heart Fail 6:279–286
Asinger RW, Hart RG, McBride R, Pearce LA, Rothbart RM (1992) Predictors of thromboembolism in atrial fibrillation: features of patients at risk. Ann Intern Med 116:6–12
Ezekowitz M, Laupacis A, Boysen G (1998) Echocardiographic predictors of stroke in patients with atrial fibrillation: a prospective study of 1066 patients from 3 clinical trials. Arch Intern Med 158:1316–1320
Gupta DK, Giugliano RP, Ruff CT, Claggett B, Murphy S, Antman E, Mercuri MF, Braunwald E, Solomon SD, Effective anticoagulation with Factor Xa Next Generation in AF–Thrombolysis in Myocardial Infarction 48 (ENGAGE AF–IMI 48) Echocardiographic Study Investigators (2016) The prognostic significance of cardiac structure and function in atrial fibrillation: the ENGAGE AF-TIMI 48 echocardiographic substudy. J Am Soc Echocardiogr 29:537–544
Olshansky B, Heller EN, Mitchell LB, Chandler M, Slater W, Green M, Brodsky M, Barrell P, Greene HL (2005) Are transthoracic echocardiographic parameters associated with atrial fibrillation recurrence or stroke? Results from the atrial fibrillation follow-up investigation of rhythm management (AFFIRM) study. J Am Coll Cardiol 45:2026–2033
Thavendiranathan P, Grant AD, Negishi T, Plana JC, Popovic ZB, Marwick TH (2013) Reproducibility of echocardiographic techniques for sequential assessment of left ventricular ejection fraction. J Am Coll Cardiol 61:77–84
Bonapace S, Valbusa F, Bertolini L, Zenari L, Canali G, Molon G, Lanzoni L, Cecchetto A, Rossi A, Mantovani A, Zoppini G, Barbieri E, Targher G (2017) Early impairment in left ventricular systolic function is associated with an increased risk of incident atrial fibrillation in patients with type 2 diabetes. J Diabetes Complicat 31:413–418
Olsen FJ, Pedersen S, Jensen JS, Biering-Sorensen T (2016) Global longitudinal strain predicts atrial fibrillation and stroke occurrence after acute myocardial infarction. Medicine 95:e5338
Takagi T, Takagi A, Yoshikawa J (2014) Elevated left ventricular filling pressure estimated by E/e' ratio after exercise predicts development of new-onset atrial fibrillation independently on left atrial enlargement among elderly patients without obvious myocardial ischemia. J Cardiol 63:128–133
Melduni RM, Suri RM, Seward JB, Bailey KR, Ammash NM, Oh JK, Schaff HV, Gersh BJ (2011) Diastolic dysfunction in patients undergoing cardiac surgery: a pathophysiological mechanism underlying the initiation of new-onset post-operative atrial fibrillation. J Am Coll Cardiol 58:953–961
Aronson D, Multlak D, Bahouth R, Hammerman H, Lessick J, Carasso S, Dabbah S, Reisner S, Agmon Y (2011) Restrictive left ventricular filling pattern and risk of new-onset atrial fibrillation after acute myocardial infarction. Am J Cardiol 107:1738–1743
Buber J, Luria D, Sternik L, Raanani E, Feinberg MS, Goldenberg I, Nof E, Gurevitz O, Eldar M, Glikson M, Kuperstein R (2011) Left atrial contractile function following a successful modified Maze procedure at surgery and the risk for subsequent thromboembolic stroke. J Am Coll Cardiol 58:1614–1621
Kim TH, Shim CY, Park JH, Nam CM, Uhm JS, Joung B, Lee MH, Pak HN (2016) Left ventricular diastolic dysfunction is associated with atrial remodeling and risk or presence of stroke in patients with paroxysmal atrial fibrillation. J Cardiol 68:104–109
Lee SH, Choi S, Chung WJ, Byun YS, Ryu SK, Pyun WB, Rim SJ (2008) Tissue Doppler index, E/E', and ischemic stroke in patients with atrial fibrillation and preserved left ventricular ejection fraction. J Neurol Sci 271:148–152
Sakabe K, Fukuda N, Fukuda Y, Morishita S, Shinohara H, Tamura Y (2009) Transthoracic echocardiography during sinus rhythm identifies elderly patients with nonvalvular paroxysmal atrial fibrillation at high risk of cerebral infarction. Int J Cardiol 136:346–348
Nagueh SF, Smiseth OA, Appleton CP, Byrd BF 3rd, Dokainish H, Edvardsen T, Flachskampf FA, Gillebert TC, Klein AL, Lancellotti P, Marino P, Oh JK, Alexandru Popescu B, Waggoner AD (2016) Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 17:1321–1360
Bang CN, Dalsgaard M, Greve AM, Køber L, Gohlke-Baerwolf C, Ray S, Rossebø AB, Egstrup K, Wachtell K (2013) Left atrial size and function as predictors of new-onset of atrial fibrillation in patients with asymptomatic aortic stenosis: the simvastatin and ezetimibe in aortic stenosis study. Int J Cardiol 168:2322–2327
Gardner JD, Skelton WP, Khouzam RN (2016) Is time to incorporate the left atrial size to the current stroke risk scoring systems for atrial fibrillation? Curr Probl Cardiol 41:251–259
Tsang TS, Abhayaratna WP, Barnes ME, Miyasaka Y, Gersh BJ, Bailey KR, Cha SS, Seward JB (2006) Prediction of cardiovascular outcomes with left atrial size: is volume superior to area or diameter? J Am Coll Cardiol 47:1018–1023
Parkash R, Green MS, Kerr CR, Connolly SJ, Klein GJ, Sheldon R, Talajic M, Dorian P, Humphries KH, Canadian Registry of Atrial Fibrillation (2004) The association of left atrial size and occurrence of atrial fibrillation: a prospective cohort study from the Canadian Registry of atrial fibrillation. Am Heart J 148:649–654
Zacà V, Galderisi M, Mondillo S, Focardi M, Ballo P, Guerrini F (2007) Left atrial enlargement as a predictor of recurrences in lone paroxysmal atrial fibrillation. Can J Cardiol 23:869–872
Marchese P, Bursi F, Delle Donne G, Malavasi V, Casali E, Barbieri A, Melandri F, Modena MG (2011) Indexed left atrial volume predicts the recurrence of non-valvular atrial fibrillation after successful cardioversion. Eur Heart J Cardiovasc Imaging 12:214–221
Benjamin EJ, D'Agostino RB, Belanger AJ, Wolf PA, Levy D (1994) Left atrial size and the risk of stroke and death. The Framingham Heart Study. Circulation 89:724–730
Paciaroni M, Agnelli G, Falocci N, Caso V, Becattini C, Marcheselli S, Rueckert C, Pezzini A, Poli L, Padovani A, Csiba L, Szabó L, Sohn SI, Tassinari T, Abdul-Rahim AH, Michel P, Cordier M, Vanacker P, Remillard S, Alberti A, Venti M, Acciarresi M, D'Amore C, Mosconi MG, Scoditti U, Denti L, Orlandi G, Chiti A, Gialdini G, Bovi P, Carletti M, Rigatelli A, Putaala J, Tatlisumak T, Masotti L, Lorenzini G, Tassi R, Guideri F, Martini G, Tsivgoulis G, Vadikolias K, Liantinioti C, Corea F, Del Sette M, Ageno W, De Lodovici ML, Bono G, Baldi A, D'Anna S, Sacco S, Carolei A, Tiseo C, Imberti D, Zabzuni D, Doronin B, Volodina V, Consoli D, Galati F, Pieroni A, Toni D, Monaco S, Baronello MM, Barlinn K, Pallesen LP, Kepplinger J, Bodechtel U, Gerber J, Deleu D, Melikyan G, Ibrahim F, Akhtar N, Lees KR (2016) Prognostic value of trans-thoracic echocardiography in patients with acute stroke and atrial fibrillation: findings from the RAF study. J Neurol 263:231–237
Lancellotti P, Galderisi M (2018) Prediction of ischaemic stroke in non-valvular atrial fibrillation if advanced echocardiography plays the game. Eur Heart J39:1426–1428
Her AY, Kim JY, Kim YH, Choi EY, Min PK, Yoon YW, Lee BK, Hong BK, Rim SJ, Kwon HM (2013) Left atrial strain assessed by speckle tracking imaging is related to new-onset atrial fibrillation after coronary artery bypass grafting. Can J Cardiol 29:377–383
Imanishi J, Tanaka H, Sawa T, Motoji Y, Miyoshi T, Mochizuki Y, Fukuda Y, Tatsumi K, Matsumoto K, Okita Y, Hirata K (2014) Left atrial booster-pump function as a predictive parameter for new-onset atrial fibrillation in patients with severe aortic stenosis. Int J Cardiovasc Imaging 30:295–304
Sade LE, Atar I, Ozin B, Yuce D, Muderrisoglu H (2016) Determinants of new-onset atrial fibrillation in patients receiving CRT: mechanicistic insights from Speckle Tracking Echocardiography. JACC Cardiovasc Imaging 9:99–111
Azemi T, Rabdiya VM, Ayirala SR, McCullough LD, Silverman DI (2012) Left atrial strain is reduced in patients with atrial fibrillation, stroke or TIA, and low risk CHADS (2) scores. J Am Soc Echocardiogr 25:1327–1332
Obokata M, Negishi K, Kurosawa K, Tateno R, Tange S, Arai M, Amano M, Kurabayashi M (2014) Left atrial strain provides incremental value for embolism risk stratification over CHA2DS2-VASc score and indicates prognostic impact in patients with atrial fibrillation. J Am Soc Echocardiogr 27:709–716.e4
Shih JY, Tsai WC, Huang YY, Liu YW, Lin CC, Huang YS, Tsai LM, Lin LJ (2011) Association of decreased left atrial strain and strain rate with stroke in chronic atrial fibrillation. J Am Soc Echocardiogr 24:513–519
Leung ML, van Rosendael PJ, Abou R, Ajmone Marsan N, Leung DY, Delgado V, Bax JJ (2018) Left atrial function to identify patients with atrial fibrillation at high risk of stroke: new insights from a large registry. Eur Heart J 39:1416–1425
Badano LP, Kolias TJ, Muraru D, Abraham TP, Aurigemma G, Edvardsen T, D'Hooge J, Donal E, Fraser AG, Marwick T, Mertens L, Popescu BA, Sengupta PP, Lancellotti P, Thomas JD, Voigt JU, Industry representatives (2018) Standardization of left atrial, right ventricular, and right atrial deformation imaging using two-dimensional speckle tracking echocardiography: a consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging. Eur Heart J Cardiovasc Imaging 19:591–600
De Bruijn SFTM, Agema WRP, Lammers GJ, van der Wall EE, Wolterbeek R, Holman ER, Bollen EL, Bax JJ (2006) Transesophageal echocardiography is superior to transthoracic echocardiography in management of patients of any age with transient ischemic attack or stroke. Stroke 37:2531–2534
De Abreu TT, Mateus S, Carreteiro C, Correia J (2008) Therapeutic implications of transesophageal echocardiography after transthoracic echocardiography on acute stroke patients. Vasc Health Risk Manag 4:167–172
Doukky R, Garcia-Sayan E, Gage H, Nagarajan V, Demopoulos A, Cena M, Nazir NT, Karam GJ, Trohman RG, Kazlauskaite R (2014) The value of diastolic function parameters in the prediction of left atrial appendage thrombus in patients with nonvalvular atrial fibrillation. Cardiovasc Ultrasound 12:10
Faustino A, Providência R, Barra S, Paiva L, Trigo J, Botelho A, Costa M, Gonçalves L (2014) Which method of left atrium size quantification is the most accurate to recognize thromboembolic risk in patients with non-valvular atrial fibrillation? Cardiovasc Ultrasound 12:28
Providência R, Botelho A, Trigo J, Quintal N, Nascimento J, Mota P, Leitão-Marques A (2012) Possible refinement of clinical thromboembolism assessment in patients with atrial fibrillation using echocardiographic parameters. Europace 14:36–45
Boyd AC, McKay T, Nasibi S, Richards DA, Thomas L (2013) Left ventricular mass predicts left atrial appendage thrombus in persistent atrial fibrillation. Eur Heart J Cardiovasc Imaging 14:269–275
Kotecha D, Mohamed M, Shantsila E, Popescu BA, Steeds RP (2017) Is echocardiography valid and reproducible in patients with atrial fibrillation? A systematic review. Europace 19:1427–1438
Staszewsky L, Latini R (2013) What is the atrium trying to tell us? Eur Heart J 34:255–257
Gupta S, Matulevicius SA, Ayers CR, Berry JD, Patel PC, Markham DW, Levine BD, Chin KM, de Lemos JA, Peshock RM, Drazner MH (2013) Left atrial structure and function and clinical outcomes in the general population. Eur Heart J34:278–285
Mandoli GE, Cameli M, Lisi E, Minardi G, Capone V, Pastore MC, Mondillo S (2019) Left atrial fractional shortening: a simple and practical "Strain" for everyone. J Cardiovasc Echogr 29(2):52–57
Prioli A, Marino P, Lanzoni L, Zardini P (1998) Increasing degrees of left ventricular filling impairment modulate left atrial function in humans. Am J Cardiol 82:756–761
Galderisi M, Donal E, Magne J, Lo Iudice F, Agricola E, Sade LE, Cameli M, Schwammenthal E, Cardim N, Cosyns B, Hagendorff A, Neskovic AN, Zamorano JL, Lancellotti P, Habib G, Edvardsen T, Popescu BA (2018) Rationale and design of the EACVI AFib Echo Europe Registry for assessing relationships of echocardiographic parameters with clinical thrombo-embolic and bleeding risk profile in non-valvular atrial fibrillation. Eur Heart J Cardiovasc Imaging 19:245–252
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Tufano, A., Galderisi, M. Can echocardiography improve the prediction of thromboembolic risk in atrial fibrillation? Evidences and perspectives. Intern Emerg Med 15, 935–943 (2020). https://doi.org/10.1007/s11739-020-02303-5
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DOI: https://doi.org/10.1007/s11739-020-02303-5