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Impact of Diastolic Function Parameters on the Risk for Left Atrial Appendage Thrombus in Patients with Nonvalvular
Rami Doukky1, Enrique Garcia-Sayan2, Mita Patel3
1Division of Adult Cardiology, John H. Stroger, Jr Hospital of Cook County, Chicago, Illinois; Division of Cardiology, Rush University Medical Center, Chicago, Illinois.
Insights
Left atrial appendage thrombus risk in nonvalvular atrial fibrillation (NVAF) patients is linked to diastolic dysfunction. Echocardiographic measures like E/e' ratio and e' velocity can identify patients at low risk for LAA thrombus.
Area of Science:
- Cardiology
- Echocardiography
- Thrombosis Research
Background:
- Left atrial appendage (LAA) thrombus is a risk in nonvalvular atrial fibrillation (NVAF).
- The relationship between LAA thrombus and left ventricular diastolic function in NVAF patients remains understudied prospectively.
Purpose of the Study:
- To prospectively investigate the association between left ventricular diastolic function parameters and LAA thrombus in NVAF patients.
- To determine if diastolic function assessment can improve stroke risk prediction in NVAF.
Main Methods:
- Prospective enrollment of NVAF patients at two academic medical centers.
- Investigational transthoracic echocardiography performed before transesophageal echocardiography.
- Measurement of mitral inflow E velocity, mitral annular velocities (e'), and calculation of E/e' ratios.
Main Results:
- LAA thrombus was present in 6.4% of 266 NVAF patients.
- Higher E/e' ratios and lower e' velocities were significantly associated with LAA thrombus.
- E/e' and e' velocity provided independent and incremental predictive value for LAA thrombus beyond the CHA2DS2-VASc score.
Conclusions:
- Left ventricular diastolic function parameters (E/e' ratio, e' velocity) are associated with LAA thrombus in NVAF patients.
- These echocardiographic measures may help identify NVAF patients at low risk for LAA thrombus.
- Diastolic function assessment could enhance stroke risk prediction in NVAF.
Background:
In patients with nonvalvular atrial fibrillation (NVAF), the impact of left ventricular diastolic function on the risk for left atrial appendage (LAA) thrombus has not been prospectively studied.
Methods:
At two academic medical centers, patients with NVAF were prospectively enrolled to undergo investigational transthoracic echocardiography immediately before clinically indicated transesophageal echocardiography. Mitral inflow E velocity and tissue Doppler septal and lateral mitral annulus velocities (e') were measured, and E/e' ratios were calculated.
Results:
Among 266 subjects (mean age, 65 years; 32% women), 17 (6.4%) had LAA thrombus. Patients with LAA thrombus had a higher mean CHA2DS2-VASc score (4.6 ± 1.7 vs 3.0 ± 1.8, P < .001), a higher mean lateral E/e' ratio (19.4 ± 10.1 vs 10.2 ± 5.6, P < .001), and a lower mean lateral e' velocity (7.0 ± 3.2 vs 10.4 ± 3.7 cm/sec, P = .001). There was a good discriminative capacity for E/e' (area under the curve, 0.83; P < .001) and e' velocity (area under the curve, 0.76; P = .001). None of the patients with normal E/e' ratios or normal e' velocities had LAA thrombus. Both E/e' (odds ratio, 1.13 per point; 95% CI, 1.06-1.20; P < .001) and e' velocity (odds ratio, 0.76 per 1 cm/sec; 95% CI, 0.63-0.92; P = .005) provided independent and incremental predictive value beyond the CHA2DS2-VASc score; however, E/e' provided greater incremental value than e' velocity (P = .036). Analyses using septal and averaged E/e' and septal e' velocity yielded similar results. Diastolic function parameters were also associated with the presence and intensity of left atrial spontaneous echo contrast, a precursor of LAA thrombus.
Conclusions:
This prospective and concomitant evaluation of diastolic function and LAA thrombus in patients with NVAF demonstrates that E/e' ratio and e' velocity are associated with LAA thrombus, independent of CHA2DS2-VASc score, and may play a role in identifying patients at low risk for LAA thrombus. These data suggest that diastolic function assessment may improve stroke prediction in patients with NVAF.
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