P4767VTE-BLEED score predicts major bleeding in patients with atrial fibrillation

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
F A Klok ◽  
K G Chu ◽  
L Valerio ◽  
S J Van Der Wall ◽  
S Barco ◽  
...  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
High Risk ◽  
Dose Reduction ◽  
Major Bleeding ◽  
Bleeding Risk ◽  
Composite Outcome ◽  
Systemic Embolism ◽  
High Risk Patients ◽  
Risk Patients

Abstract Background Bleeding risk scores in atrial fibrillation (AF) are used to identify risk factors for bleeding but not to determine anticoagulant therapy since high bleeding risk strongly correlates to high risk of stroke. VTE-BLEED is a simple bleeding risk score (Klok FA Eur Respir J 2016) that predicts major bleeding (MB) in patients with venous thromboembolism, but has never been evaluated in AF. Aims To evaluate VTE-BLEED in AF and whether dabigatran dose reduction in VTE-BLEED high-risk patients would result in a lower incidence of MB and the composite endpoint of MB plus stroke/systemic embolism. Methods Assessment of VTE-BLEED in 18040 patients of the RE-LY trial (Connolly SJ NEJM 2009) that compared dabigatran (both 150mg BID and 110mg BID) to warfarin. The score was calibrated to fit the AF population. Hazard ratios (HR) were obtained for the VTE-BLEED high-risk patients randomized to dabigatran. The risk ratios for MB and the composite outcome of MB plus stroke/systemic embolism between dabigatran 150mg and 110mg were calculated for the VTE-BLEED high-risk group. Results The adapted VTE-BLEED score classified 4060 patients (22.5%) as high-risk. A high score indeed predicted MB in patients treated with dabigatran 150mg BID or 110mg BID, for HRs of 2.48 (95% CI 1.96–3.13) and 2.61 (95% CI 2.04–3.33), respectively. In VTE-BLEED high-risk patients, the risk ratio between the two dabigatran doses was 0.53 (95% CI 0.35–0.78) for MB and 0.55 (95% CI 0.38–0.79) for the composite outcome, both in favor of dabigatran 110mg BID (Figure 1). Compared to the current European label of dabigatran, application of VTE-BLEED to determine dabigatran dosing would result in a different dose for 21% of patients. Figure 1 Conclusions VTE-BLEED was validated for AF. Our data suggest that dabigatran dose reduction in VTE-BLEED bleed high-risk patients -in addition to targeting individual modifiable risk factors for bleeding- may lower the risk of MB and improve patient outcome. This finding could have important clinical implications but should be confirmed in future studies.

Tailoring anticoagulant treatment of patients with atrial fibrillation using a novel bleeding risk score

Heart ◽  
2020 ◽  
pp. heartjnl-2019-316305
Author(s):  
Gordon Chu ◽  
Luca Valerio ◽  
Sake J van der Wall ◽  
Stefano Barco ◽  
Stavros Konstantinides ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
High Risk ◽  
Dose Reduction ◽  
Risk Score ◽  
Bleeding Risk ◽  
Composite Outcome ◽  
Risk Of Bleeding ◽  
Risk Patients ◽  
High Bleeding Risk ◽  
Dose Reductions

ObjectivesCurrent international guidelines advocate the application of bleeding risk scores only to identify modifiable risk factors, but not to withhold treatment in patients at high risk of bleeding. VTE-BLEED (ActiVe cancer, male with uncontrolled hyperTension, anaEmia, history of BLeeding, agE and rEnal Dysfunction) is a simple bleeding risk score that predicts major bleeding (MB) in patients with venous thromboembolism, but has never been evaluated in patients with atrial fibrillation (AF). We sought to evaluate VTE-BLEED in patients with AF included in the Randomised Evaluation of Long-term anticoagulant therapY (RE-LY) trial, to assess whether score classes (high vs low bleeding risk) interact with the tested dabigatran doses (150 vs 110 mg twice daily), and to investigate whether dose reductions based on this interaction might help to lower the incidence of the composite outcome MB, stroke/systemic embolism or death.MethodsThe score was calculated in the safety population of RE-LY (n=18 040) and recalibrated for AF (AF-adapted VTE-BLEED or AF-BLEED). HRs were calculated to evaluate the score’s predictive accuracy for MB. The risk ratios (RRs) for the composite outcome comparing dabigatran 150 and 110 mg twice daily were calculated for the high-risk group.ResultsAF-BLEED classified 3534 patients (19.6%) at high bleeding risk, characterised by a 2.9-fold to 3.4-fold higher risk of bleeding than low bleeding risk patients, across the treatment arms. High bleeding risk patients randomised to 110 mg twice daily had a lower incidence of the composite outcome than those randomised to 150 mg twice daily, for an RR of 0.52 (95% CI 0.35 to 0.78). Compared with the label criteria for dose reduction, AF-BLEED identified an additional 11% of patients who might have benefited from dose reduction.ConclusionsAF-BLEED identified patients with AF at high risk of bleeding. Our findings raise the hypothesis that dabigatran 110 mg twice daily might be considered in patients classified as high risk according to the AF-BLEED score. This study provides a basis for future studies to explore safe dose reductions of direct oral anticoagulants in selected patient groups based on bleeding scores.

Long-term outcomes of Japan-specific dosage of rivaroxaban in high-risk patients with non-valvular atrial fibrillation: analysis from the XAPASS

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
T Ikeda ◽  
S Ogawa ◽  
T Kitazono ◽  
J Nakagawara ◽  
K Minematsu ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
High Risk ◽  
Major Bleeding ◽  
Factor Xa ◽  
Incidence Rates ◽  
Funding Source ◽  
High Risk Patients ◽  
Reduced Dose ◽  
Risk Patients

Abstract Background XAPASS is a real-world, prospective, single-arm, observational study conducted as a post-marketing surveillance mandated by the health authority in Japan. Nowadays, direct oral anticoagulant therapy using factor Xa or thrombin inhibitor has been the standard of care for patients with non-valvular atrial fibrillation (NVAF) to prevent ischemic stroke. However, the clinical impact of reduced dosage (approved dose of 15 or 10 mg once daily in Japan is relatively reduced compared to global dosage) factor Xa inhibitor rivaroxaban in high-risk patients remains unclear. Purpose The present sub-analysis of XAPASS was carried out to assess long-term safety and effectiveness of reduced-dose rivaroxaban in high-risk NVAF patients for bleeding and thromboembolism. Methods All patients with NVAF who were newly started on rivaroxaban were eligible for surveillance. The principal safety outcome was a composite of major and non-major bleeding events, and the primary effectiveness outcome was a composite of ischaemic stroke, haemorrhagic stroke, non-central nervous system systemic embolism (non-CNS SE), and myocardial infarction (MI). In this present sub-analysis, high-risk patients were defined as those who had two of the following three risk factors: elderly (≥75 years old), low body weight (≤50 kg), and renal impairment (CrCl <50 mL/min). Results In total, 11,308 patients were enrolled between April 2012 and June 2014 from 1,419 hospitals, and overall data were analysed from 10,664 patients from whom data were collected. Among them, 3,694 patients matched the criteria for the high-risk patients defined in this sub-analysis, and 6,970 patients did not match the criteria (non-high-risk patients). The mean treatment duration was 791±673 days in the high-risk patients and 944±709 days in the non-high-risk patients. Mean patient age was 80.9±5.5 years and 69.0±9.0 years at baseline, respectively. Mean CHADS2 score was 2.8 and 1.8, and CHA2DS2-VASc score was 4.4 and 2.9, respectively. The rates of CHADS2 component comorbidities were lower in the non-high-risk patients except for diabetes mellitus. The incidence rates of any bleeding, major bleeding, and the primary effectiveness outcomes were 4.8, 1.6, and 2.1%/patient-year in the high-risk patients. The incidence rates of these clinical events in the non-high-risk patients were 3.3, 0.9, and 1.0%/patient-year, respectively. Conclusions Incidence rates of long-term bleeding and thromboembolism were higher in the high-risk patients than in the non-high-risk patients. However, the rates of these outcomes using the Japan-specific reduced dose were not so high. Furthermore, the balance between safety and effectiveness outcomes was within an acceptable range. The present study provides useful information for physicians to stratify high-risk patients using the reduced dose in daily clinical practice. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Bayer Yakuhin Ltd.

scholarly journals Cardiovascular outcomes, bleeding risk, and achieved blood pressure in patients on long-term anticoagulation with the thrombin antagonist dabigatran or warfarin: data from the RE-LY trial

2020 ◽  
Vol 41 (30) ◽  
pp. 2848-2859 ◽  
Author(s):  
Michael Böhm ◽  
Martina Brueckmann ◽  
John W Eikelboom ◽  
Michael Ezekowitz ◽  
Mandy Fräßdorf ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Blood Pressure ◽  
High Risk ◽  
Major Bleeding ◽  
Oral Anticoagulation ◽  
Bleeding Events ◽  
High Risk Patients ◽  
Increased Risk ◽  
Risk Patients

Abstract Aims A J-shaped association of cardiovascular events to achieved systolic (SBP) and diastolic (DBP) blood pressure was shown in high-risk patients. This association on oral anticoagulation is unknown. This analysis from RELY assessed the risks of death, stroke or systemic emboli, and bleeding according to mean achieved SBP and DBP in atrial fibrillation on oral anticoagulation. Methods and results RE-LY patients were followed for 2 years and recruited between 22 December 2005 until 15 December 2007. 18.113 patients were randomized in 951 centres in 54 countries and 18,107 patients with complete blood pressure (BP) data were analysed with a median follow-up of 2.0 years and a complete follow-up in 99.9%. The association between achieved mean SBP and DBP on all-cause death, stroke and systemic embolic events (SSE), major, and any bleeding were explored. On treatment, SBP >140 mmHg and <120 mmHg was associated with all-cause death compared with SBP 120–130 mmHg (reference). For SSE, risk was unchanged at SBP <110 mmHg but increased at 140–160 mmHg (adjusted hazard ratio (HR) 1.81; 1.40–2.33) and SBP ≥160 mmHg (HR 3.35; 2.09–5.36). Major bleeding events were also increased at <110 mmHg and at 110 to <120 mmHg. Interestingly, there was no increased risk of major bleeding at SBP >130 mmHg. Similar patterns were observed for DBP with an increased risk at <70 mmHg (HR 1.55; 1.35–1.78) and >90 mmHg (HR 1.88; 1.43–2.46) for all-cause death compared to 70 to <80 mmHg (reference). Risk for any bleeding was increased at low DBP <70 mmHg (HR 1.46; 1.37–1.56) at DBP 80 to <90 mmHg (HR 1.13; 1.06–1.31) without increased risk at higher achieved DBP. Dabigatran 150 mg twice daily showed an advantage in all patients for all-cause death and SSE and there was an advantage for 110 mg dabigatran twice daily for major bleeding and any bleeding irrespective of SBP or DBP achieved. Similar results were obtained for baseline BP, time-updated BP, and BP as time-varying covariate. Conclusion Low achieved SBP associates with increased risk of death, SSE, and bleeding in patients with atrial fibrillation on oral anticoagulation. Major bleeding events did not occur at higher BP. Low BP might identify high-risk patients not only for death but also for high bleeding risks. Clinical trial registration  ClinicalTrials.gov—Identifier: NCT00262600.

Abstract 19108: Anticoagulation Treatment in High-Risk Medicare Advantage Patients with Non-Valvular Atrial Fibrillation

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Amanda S Bruno ◽  
Jeffrey N Trocio ◽  
Daniel Wiederkehr ◽  
Younos Abdulsattar ◽  
Joette Gdovin ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
High Risk ◽  
Major Bleeding ◽  
Oral Anticoagulants ◽  
Treatment Options ◽  
Medicare Advantage ◽  
Risk Levels ◽  
High Risk Patients ◽  
Index Stroke ◽  
Risk Patients

OBJECTIVE: Examine anticoagulation (AC) treatment in Medicare Advantage Prescription Drug (MAPD) plan members diagnosed with non-valvular atrial fibrillation (NVAF) and at high risk for stroke. METHODS: A retrospective analysis of claims data from a large US health plan was conducted. Patients with NVAF were identified between 1/1/2011 and 11/30/2013. Index date was based on NVAF diagnosis and patients were required to have ≥18 months of continuous enrollment: 6 months pre-index and 12 months post-index. Pre-index stroke risk was calculated using the CHADS 2 . Patients classified as high risk (CHADS 2 score ≥2) were included in the analysis. Post-index AC treatment options were warfarin and novel oral anticoagulants (NOACs), dabigatran, apixaban, rivaroxaban. The proportion of high-risk patients with time in therapeutic range (TTR)≥60% was calculated among those receiving warfarin with ≥2 INR values within a 3-month period. Adherence among high-risk patients receiving a NOAC or warfarin without available INR values was calculated using the proportion of days covered (PDC)≥80%. Risk for major bleeding was also calculated using the HASBLED score. Descriptive statistics were used to summarize AC treatment. FINDINGS: Of 93,864 patients with NVAF, 70,646 were identified as high risk for stroke. Among them, 36,601 (51.8%) were treated with an AC while 34,045 (48.1%) did not receive any AC treatment during post-index. Of those treated with an AC, 30,802 (84.2%) were treated with warfarin and 5,799 (15.8%) were treated with a NOAC. TTR was calculated for 7,034 (22.8%) of those receiving warfarin, of which 3,215 (45.7%) had a TTR≥60%. PDC≥80% was observed for 13,758 (57.9%) of the remaining warfarin users and 3,353 (58.7%) of NOAC users. A total of 64,191 (90.8%) patients had a HASBLED score ≥3. CONCLUSIONS: A large proportion of NVAF patients at high risk for stroke are untreated or potentially undertreated_as evidenced by the low TTR values and low adherence estimates observed here. These patients’ high risk levels for stroke and major bleeding necessitate optimal prophylactic treatment with AC and careful management. Further research with providers may identify potential causes for non-treatment and undertreatment with AC in high risk NVAF patients.

EVALUATION OF PREOPERATIVE HEMOSTATIC SCREENING

1987 ◽  
Author(s):  
J A Caprini ◽  
A Mitchell ◽  
L Rao ◽  
J P Vagher
Keyword(s):  
Risk Factors ◽  
High Risk ◽  
Predictive Accuracy ◽  
Postoperative Bleeding ◽  
Bleeding Risk ◽  
High Risk Group ◽  
Low Risk ◽  
Surgical Patients ◽  
High Risk Patients ◽  
Risk Patients

The records of 705 surgical patients were reviewed to ccrrpare the value of history, bleeding risk factors, preoperative template bleeding time (BT) and activated partial thromboplastin time (APTT) in predicting excessive operative bleeding and/or the need for intra or postoperative transfusion. Bleeding was classified as normal or excessive by a panel of physicians evaluating operative blood loss, operative pathology including trauna, postoperative hematocrit, tube drainage, wound hematoma, etc. These assessments were compared with the incidence of intra/postoperative blood transfusions. 25% of the patients had excessive intra/postoperative bleeding and 35% of the population were transfused. A BT > 10 minutes and an APTT > 111% of pooled-normal-piasma were considered abnormal. 9.6% of patients had an abnormal BT and showed a statistically significant higher incidence of bleeding (42.6%) and transfusion (58.8%) compared with a 23.2% incidence of bleeding and 32.3% incidence of transfusion in those with a normal BT (p< 0.001). 18.7% of patients had an abnormal APTT and 31.8% bled compared to 23.6% of those with a normal APTT (p< 0.05). When both tests were abnormal, 54.5% bled compared to 22.4% when the tests were normal (p< 0.001). When both tests were abnormal 63.6% were transfused whereas only 32.1% with normal tests were transfused (p< 0.005). 72.5% of the 705 patients were considered high risk because of a history of bleeding, drug ingestion, cancer, sepsis, trauma, clinical bleeding, diabetes, uremia, or cardiovascular surgery. 76.3% of the patients who bled at surgery came from this high risk group. Of the high risk patients, those with an abnormal BT bled more often (42.9%) (p< 0.005) and were transfused more (60.3%) (p< 0.001) than those high risk patients with a normal BT (24.2% bled and 36.4% were transfused). Although a greater percentage of high risk patients with an abnormal APTT bled and were transfused, the comparisons were not statistically significant. Patients with abnormal tests, regardless of history, whose surgery was delayed because of the test results bled less often (13.8%) than those whose surgery was not delayed despite abnormal tests (34.8%) (p< 0.05). 14.4% of patients without any history or risk factors (Low Risk) had abnormal tests and bled more often than those low risk patients with normal tests but the comparison was not statistically significant. These results suggest that a combination of history, high risk factors, BT and APTT can better identify surgical patients more likely to bleed excessively or require transfusions than any one parameter. No combination of parameters will identify all bleeders, but including these two tests increases predictive accuracy in certain groups. We feel the cost of these two tests ($40) is much less than the potential expense of unexpected bleeding, particularly if transfusions are required or transfusion related complications occur.

P4752Apixaban 2.5 mg twice daily is effective and safe for patients with atrial fibrillation and combinations of advanced age, low body weight, and elevated creatinine: insights from ARISTOTLE

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M Zeitouni ◽  
A Giczewska ◽  
R D Lopes ◽  
D Wojdyla ◽  
C Christersson ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Dose Reduction ◽  
Major Bleeding ◽  
Plasma Concentrations ◽  
Similar Efficacy ◽  
Efficacy And Safety ◽  
Systemic Embolism ◽  
Risk Patients ◽  
Elevated Creatinine ◽  
The Relationship

Abstract Background In ARISTOTLE, patients with atrial fibrillation and ≥2 dose-reduction criteria [age ≥80 years, weight ≤60 kg, and creatinine ≥1.5 mg/dL (133 μmol/L)] were randomized to apixaban 2.5 mg twice daily (b.i.d) or warfarin. Purpose To determine whether the apixaban dose adjustment in ARISTOTLE resulted in similar efficacy and safety compared to warfarin. Methods The effects of apixaban 2.5 mg b.i.d versus warfarin on stroke or systemic embolism, major bleeding and death in ARISTOTLE patients with ≥2 dose-reduction criteria were compared with the effects of apixaban 5 mg b.i.d in patients with 0 or 1 dose-reduction criterion. Results Of 751 (4.1%) patients with ≥2 dose-reduction criteria, 386 were assigned to apixaban 2.5 mg b.i.d and 365 to warfarin. Compared to patients with 0 or 1 dose reduction criteria (n=17,322), these patients had a higher risks of stroke/systemic embolism (HR =1.78; 95% CI [1.24–2.57]), major bleeding (HR =1.73; 95% CI [1.28–2.32]) and death (HR=3.21; 95% CI [2.69–3.83]), irrespective of whether they were assigned to apixaban or warfarin. The benefits of apixaban 2.5 mg b.i.d compared with warfarin on stroke or systemic embolism, major bleeding, and death in patients with ≥2 dose-reduction criteria were consistent with that of apixaban 5 mg b.i.d in patients with either 0 or 1 dose-reduction criteria (Figure). Conclusions While they are at higher overall risk, patients with appropriate dose reduction criteria have consistent benefits with apixaban 2.5 mg b.i.d. over warfarin. Additional analyses investigating the relationship between apixaban dose and both apixaban plasma concentrations and levels of thrombosis biomarkers are underway. Acknowledgement/Funding Bristol-Myers Squibb and Pfizer, Inc.

scholarly journals Personalizing the decision of dabigatran versus warfarin in atrial fibrillation: A secondary analysis of the Randomized Evaluation of Long-term anticoagulation therapY (RE-LY) trial

PLoS ONE ◽  
2021 ◽  
Vol 16 (8) ◽  
pp. e0256338
Author(s):  
Samuel W. Reinhardt ◽  
Nihar R. Desai ◽  
Yuanyuan Tang ◽  
Philip G. Jones ◽  
Jeremy Ader ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Major Bleeding ◽  
Anticoagulation Therapy ◽  
Bleeding Risk ◽  
Systemic Embolism ◽  
Randomized Evaluation ◽  
Risk Patients ◽  
The Mean ◽  
Prior Stroke

Background The RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) trial demonstrated that higher-risk patients with atrial fibrillation had lower rates of stroke or systemic embolism and a similar rate of major bleeding, on average, when treated with dabigatran 150mg compared to warfarin. Since population-level averages may not apply to individual patients, estimating the heterogeneity of treatment effect can improve application of RE-LY in clinical practice. Methods and results For 18040 patients randomized in RE-LY, we used patient-level data to develop multivariable models to predict the risk for stroke or systemic embolism and for major bleeding including all three treatment groups (dabigatran 110mg, dabigatran 150mg, and warfarin) over a median follow up of 2.0 years. The mean predicted absolute risk reduction (ARR) for stroke/systemic embolism with dabigatran 150mg compared to warfarin was 1.32% (range 11.6% lower to 3.30% higher risk). The mean predicted ARR for bleeding was 0.41% (range 8.93% lower to 63.4% higher risk). Patients with increased stroke/systemic embolism risk included those with prior stroke/TIA (OR 2.01), diabetics on warfarin (OR 2.00), and older patients on dabigatran 150mg (OR 1.68 for every 10-year increase). Major bleeding risk was higher in patients on aspirin (OR 1.25), with a history of diabetes (OR 1.34) or prior stroke/TIA (OR 1.22), those with heart failure on dabigatran 110mg (OR 1.52), older patients on either dabigatran 110mg or 150mg (OR 1.57 and 1.93, respectively, for each 10-year increase), and heavier patients on dabigatran 110mg or 150mg; patients in a region outside the United States and Canada and with better renal function had lower bleeding risk. Conclusions There is substantial heterogeneity in the benefits and risks of dabigatran relative to warfarin among patients with atrial fibrillation. Using individualized estimates may enable shared decision making and facilitate more appropriate use of dabigatran; as such, it should be prospectively tested. Clinical trial registration www.clinicaltrials.gov number, NCT00262600.

Behavioral Emergencies and Crises

2010 ◽  
pp. 739-762
Author(s):  
Phillip M. Kleespies ◽  
Justin M. Hill
Keyword(s):  
Mental Health ◽  
Risk Factors ◽  
High Risk ◽  
Work Environment ◽  
Emotional Impact ◽  
High Risk Patients ◽  
Risk Patients ◽  
Life Threatening ◽  
Behavioral Emergencies ◽  
And Training

This chapter illustrates the mental health clinician’s relationship with behavioral emergencies. The chapter begins by distinguishing the terms behavioral emergency and behavioral crisis, and underlying themes among all behavioral emergencies are identified. Given that most clinicians will face a behavioral emergency in their careers, the importance of enhancing the process of educating and training practitioners for such situations far beyond the minimal training that currently exists is highlighted. The chapter continues by exploring various aspects of evaluating and managing high-risk patients (i.e., those who exhibit violent tendencies toward themselves or others, and those at risk for victimization). It includes a discussion of the benefits and limitations to estimating life-threatening risk factors and specific protective factors. The chapter concludes by discussing the emotional impact that working with high-risk patients has on clinicians, and an emphasis is placed on the importance of creating a supportive work environment.

Right Atrial Thrombosis and Pulmonary Embolism: A Narrative Review

2020 ◽  
Vol 46 (08) ◽  
pp. 895-907
Author(s):  
Nina D. Anfinogenova ◽  
Oksana Y. Vasiltseva ◽  
Alexander V. Vrublevsky ◽  
Irina N. Vorozhtsova ◽  
Sergey V. Popov ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Embolism ◽  
High Risk ◽  
Transesophageal Echocardiography ◽  
Three Dimensional ◽  
Right Atrial ◽  
Treatment Protocols ◽  
High Risk Patients ◽  
Risk Patients ◽  
The Right

AbstractPrompt diagnosis of pulmonary embolism (PE) remains challenging, which often results in a delayed or inappropriate treatment of this life-threatening condition. Mobile thrombus in the right cardiac chambers is a neglected cause of PE. It poses an immediate risk to life and is associated with an unfavorable outcome and high mortality. Thrombus residing in the right atrial appendage (RAA) is an underestimated cause of PE, especially in patients with atrial fibrillation. This article reviews achievements and challenges of detection and management of the right atrial thrombus with emphasis on RAA thrombus. The capabilities of transthoracic and transesophageal echocardiography and advantages of three-dimensional and two-dimensional echocardiography are reviewed. Strengths of cardiac magnetic resonance imaging (CMR), computed tomography, and cardiac ventriculography are summarized. We suggest that a targeted search for RAA thrombus is necessary in high-risk patients with PE and atrial fibrillation using transesophageal echocardiography and/or CMR when available independently on the duration of the disease. High-risk patients may also benefit from transthoracic echocardiography with right parasternal approach. The examination of high-risk patients should involve compression ultrasonography of lower extremity veins along with the above-mentioned technologies. Algorithms for RAA thrombus risk assessment and protocols aimed at identification of patients with RAA thrombosis, who will potentially benefit from treatment, are warranted. The development of treatment protocols specific for the diverse populations of patients with right cardiac thrombosis is important.

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