SAT-468 Anticoagulation Conundrum: A Case Of Embolic Stroke Due To Thyrotoxic Atrial Fibrillation

Abstract Background: Thyrotoxicosis is not incorporated into any of the atrial fibrillation (AF) CVA risk stratification methods, including CHADS2VASc, as neither the American College of Cardiology/American Heart Association nor the American College of Chest Physicians view it as an independent risk factor of CVA. However, the literature has reported numerous cases of patients with thyrotoxic AF and low CHADS2VASc scores who developed CVA. It is unclear which patients with thyrotoxic AF would benefit from prophylactic anticoagulation (AC). Clinical Case: A 50-year-old male without past medical history presented for palpitations. He was found to be in AF with rapid ventricular rate. Labs revealed thyrotoxicosis (TSH <0.010 [RR 0.34-5.6 μIU/mL], FT4 3.57 [RR 0.61-1.64 ng/dL], FT3 5.26 [RR 2.5-4.5 pg/mL], and TSI negative). He was started on methimazole but no AC, as his CHADS2VASc score was 0. A few hours after admission, he developed a right-sided facial droop and weakness & aphasia. CT head showed acute left MCA infarct. CTA head/neck revealed occlusive embolus in the distal left M1 segment. He underwent IR-guided embolectomy and received intra-arterial tPA. Echocardiogram did not show thrombi or atrial level shunt but showed right atrial dilation. After extensive work-up, etiology of CVA was determined most likely a cardioembolic source due to thyrotoxic AF. Patient was treated with PTU and steroids initially for two days due to recent contrast exposure (CTA and embolectomy) and poor neurologic status, in order to obtain the added benefit of decreased T4 to T3 peripheral conversion. Patient was started on AC two weeks after his CVA (given initial risk of hemorrhagic conversion due to large CVA burden), at which time his weakness and aphasia were slowly improving, but he remained with significant neurologic deficits. Discussion : The current thought that thyrotoxicosis is not an independent risk factor of CVA in patients with AF has led to recommendations against prophylactic AC for this specific group. Although recent research has suggested that patients with thyrotoxic AF are at a lower risk of CVA than patients with non-thyrotoxic AF, there have still been many reported cases of CVA in patients who have thyrotoxic AF but no other risk factors for CVA. This discrepancy in association between thyrotoxic AF and CVA needs to be clarified. Conclusion: This case of a middle-aged man with thyrotoxic AF who developed a debilitating CVA after being treated according to his CHADS2VASC score of 0 (he was not given prophylactic AC) mirrors multiple cases in the literature. It highlights the potential benefit of examining thyrotoxic patients with AF more closely in order to more effectively risk stratify them for CVA or further exploring the relationship between thyrotoxicosis and CVA. This may help to identify more patients who could benefit from AC and thus prevent devastating consequences of CVA.

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GW29-e0540 Left ventricular-to-right atrial shunt is an independent risk factor of atrial fibrillation

Journal of the American College of Cardiology ◽

10.1016/j.jacc.2018.08.637 ◽

2018 ◽

Vol 72 (16) ◽

pp. C136

Author(s):

Hongxia Chen ◽

Hongda Chou ◽

Haili Wang ◽

Yuanyuan Xu ◽

Fei Han ◽

...

Keyword(s):

Atrial Fibrillation ◽

Risk Factor ◽

Independent Risk Factor ◽

Left Ventricular ◽

Right Atrial ◽

Atrial Shunt

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Should the Presence or Extent of Coronary Artery Disease be Quantified in the CHA2DS2-VASc Score in Atrial Fibrillation? A Report from the Western Denmark Heart Registry

Thrombosis and Haemostasis ◽

10.1055/s-0038-1675401 ◽

2018 ◽

Vol 118 (12) ◽

pp. 2162-2170 ◽

Cited By ~ 11

Author(s):

Kamilla Steensig ◽

Kevin Olesen ◽

Troels Thim ◽

Jens Nielsen ◽

Svend Jensen ◽

...

Keyword(s):

Atrial Fibrillation ◽

Coronary Artery Disease ◽

Risk Factor ◽

Coronary Artery ◽

Coronary Angiography ◽

Ischaemic Stroke ◽

Independent Risk Factor ◽

Oral Anticoagulants ◽

Increased Risk ◽

Artery Disease

Background Patients with atrial fibrillation (AF) have an increased risk of ischaemic stroke. The risk can be predicted by the CHA2DS2-VASc score, in which the vascular component refers to previous myocardial infarction, peripheral artery disease and aortic plaque, whereas coronary artery disease (CAD) is not included. Objectives This article explores whether CAD per se or extent provides independent prognostic information of future stroke among patients with AF. Materials and Methods Consecutive patients with AF and coronary angiography performed between 2004 and 2012 were included. The endpoint was a composite of ischaemic stroke, transient ischaemic attack and systemic embolism. The risk of ischaemic events was estimated according to the presence and extent of CAD. Incidence rate ratios (IRR) were calculated in reference to patients without CAD and adjusted for parameters included in the CHA2DS2-VASc score and treatment with anti-platelet agents and/or oral anticoagulants. Results Of 96,430 patients undergoing coronary angiography, 12,690 had AF. Among patients with AF, 7,533 (59.4%) had CAD. Mean follow-up was 3 years. While presence of CAD was an independent risk factor for the composite endpoint (adjusted IRR, 1.25; 1.06–1.47), extent of CAD defined as 1-, 2-, 3- or diffuse vessel disease did not add additional independent risk information. Conclusion Presence, but not extent, of CAD was an independent risk factor of the composite thromboembolic endpoint beyond the components already included in the CHA2DS2-VASc score. Consequently, we suggest that significant angiographically proven CAD should be included in the vascular disease criterion in the CHA2DS2-VASc score.

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Long Sleep Duration Is an Independent Risk Factor for Incident Atrial Fibrillation in a Chinese Population: A Prospective Cohort Study

Scientific Reports ◽

10.1038/s41598-017-04034-8 ◽

2017 ◽

Vol 7 (1) ◽

Cited By ~ 6

Author(s):

Qiaofeng Song ◽

Xiaoxue Liu ◽

Wanning Hu ◽

Wenhua Zhou ◽

Aijuan Liu ◽

...

Keyword(s):

Atrial Fibrillation ◽

Risk Factor ◽

Cohort Study ◽

Sleep Duration ◽

Prospective Cohort Study ◽

Prospective Cohort ◽

Chinese Population ◽

Independent Risk Factor ◽

Long Sleep

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Effects of atrial fibrillation on left and right atrial dimensions, pressures, and compliances

AJP Heart and Circulatory Physiology ◽

10.1152/ajpheart.1993.264.4.h1093 ◽

1993 ◽

Vol 264 (4) ◽

pp. H1093-H1097 ◽

Cited By ~ 5

Author(s):

E. Leistad ◽

G. Christensen ◽

A. Ilebekk

Keyword(s):

Atrial Fibrillation ◽

Right Atrial ◽

Ventricular Rate ◽

Maximal Diameter ◽

Filling Phase ◽

Left And Right ◽

Wave Rose ◽

V Wave ◽

The Right ◽

Complete Av Block

The effects of atrial fibrillation on left and right atrial dimensions, pressures, and compliances were examined in two groups of seven barbiturate-anesthetized open-chest pigs. Atrial diameters and pressures were recorded during atrioventricular (AV) pace and thereafter during atrial fibrillation. Both rhythms were studied with constant ventricular rate after complete AV block. Left atrial maximal diameter, which appeared at the end of the atrial filling phase, decreased from 32.4 (28.9-36.7; median and 95% confidence interval) to 31.3 (28.4-35.7) mm after induction of atrial fibrillation. The right atrial maximal diameter also decreased, although not significantly. Atrial pressure at the peak of the v wave rose from 7.0 (5.5-8.5) to 9.6 (8.3-11.2) mmHg in the left atrium and from 5.0 (4.3-5.6) to 7.3 (6.2-8.7) mmHg in the right atrium. Left and right atrial chamber stiffness constants increased from 0.25 (0.19-0.48) to 0.41 (0.28-0.66) mm-1 and from 0.21 (0.11-0.31) to 0.33 (0.30-0.39) mm-1, respectively. Instantaneous diastolic atrial compliance decreased in both atria after induction of atrial fibrillation. Thus, during atrial fibrillation with regular ventricular rate, changes in atrial diameter, pressure, and compliance take place.

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Atrial fibrillation as an independent risk factor for stroke: the Framingham Study.

Stroke ◽

10.1161/01.str.22.8.983 ◽

1991 ◽

Vol 22 (8) ◽

pp. 983-988 ◽

Cited By ~ 3874

Author(s):

P A Wolf ◽

R D Abbott ◽

W B Kannel

Keyword(s):

Atrial Fibrillation ◽

Risk Factor ◽

Independent Risk Factor ◽

Framingham Study

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Lower preoperative fluctuation of heart rate variability is an independent risk factor for postoperative atrial fibrillation in patients undergoing major pulmonary resection

Interactive Cardiovascular and Thoracic Surgery ◽

10.1093/icvts/ivt238 ◽

2013 ◽

Vol 17 (4) ◽

pp. 680-686 ◽

Cited By ~ 13

Author(s):

P. Ciszewski ◽

J. Tyczka ◽

J. Nadolski ◽

M. Roszak ◽

W. Dyszkiewicz

Keyword(s):

Atrial Fibrillation ◽

Heart Rate ◽

Heart Rate Variability ◽

Risk Factor ◽

Independent Risk Factor ◽

Pulmonary Resection ◽

Postoperative Atrial Fibrillation

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Preoperative atrial fibrillation is an independent risk factor for mid-term mortality after concomitant aortic valve replacement and coronary artery bypass graft surgery

Interactive CardioVascular and Thoracic Surgery ◽

10.1093/icvts/ivs538 ◽

2013 ◽

Vol 16 (4) ◽

pp. 488-494 ◽

Cited By ~ 18

Author(s):

Akshat Saxena ◽

Diem Dinh ◽

Jim Dimitriou ◽

Christopher Reid ◽

Julian Smith ◽

...

Keyword(s):

Atrial Fibrillation ◽

Risk Factor ◽

Coronary Artery ◽

Aortic Valve ◽

Aortic Valve Replacement ◽

Coronary Artery Bypass Graft ◽

Independent Risk Factor ◽

Artery Bypass ◽

Bypass Graft ◽

Artery Bypass Graft

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The right atrial diameter as a risk factor predicting recurrence of atrial fibrillation after catheter ablation at mid-term follow-up

10.21203/rs.3.rs-23323/v1 ◽

2020 ◽

Author(s):

Wang Xiaofei ◽

Wang Wenli ◽

Zou Cao

Keyword(s):

Risk Factor ◽

Independent Risk Factor ◽

Cox Regression ◽

Survival Curve ◽

Right Atrial ◽

Cutoff Value ◽

Kaplan Meier ◽

Significant Difference ◽

Meier Survival Curve

Abstract Background Left atrial diameter (LAD) has been confirmed to predict recurrence of atrial fibrillation (AF) after catheter ablation (CA). The influence of right atrium (RA) size on the prognosis after CA was relatively unclear and lack of research. The objective of the present study was to investigate the relationship between right atrial diameter (RAD) and the mid-term outcome of AF after CA. Methods This study retrospectively examined 121 patients who underwent initial CA for symptomatic AF. Cox regression model was used to find risk factors of recurrence. Receiver operating characteristic (ROC) curve was used to evaluate predictive power and determine clinic cutoff value. Kaplan-Meier survival curve and log-rank test were used to analyze success rate. Results There were 94 (77.7%) patients of freedom from AF after 24.2 ± 4.5 months’ follow-up. Multivariate Cox regression analysis showed both hypertension and RAD were independent risk factors of arrhythmia recurrence after ablation regardless of AF type (HR: 4.915; 95% CI: 1.370-17.635; P = 0.015 and HR: 1.059; 95% CI: 1.001–1.120; P = 0.045, respectively). However, in patients with paroxysmal AF (par-AF), Multivariate analysis showed RAD become the only independent risk factor (HR: 1.031; 95% CI: 1.016–1.340; P = 0.029). ROC curve demonstrated the cutoff value of RAD was 35.5 mm with an area under the curve (AUC) of 0.715 (95% CI: 0.586–0.843, P = 0.009), sensitivity of 81.3% and specificity of 54.2%. Kaplan-Meier survival curve showed significant difference of freedom from par-AF (67.5 vs. 91.4%, log-rank, P = 0.015) between patients with RAD ≥ 35.5 mm and < 35.5 mm in this subgroup. Nevertheless, in patients with persistent AF (per-AF), no risk factor of arrhythmia recurrence was found. In addition, Kaplan-Meier survival curve showed no significant difference of freedom from per-AF (69.7 vs. 87.5%, log-rank, P = 0.31) between patients with RAD ≥ 35.5 mm and < 35.5 mm. Conclusions RAD was the independent risk factor predicting recurrence of AF after CA only in patients with par-AF. In patients with RAD < 35.5 mm, there was a significantly higher freedom from par-AF recurrence compared with RAD ≥ 35.5 mm after a mid-term follow-up.

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