Echocardiographic Risk Factors for Stroke and Outcomes in Patients With Atrial Fibrillation Anticoagulated With Apixaban or Warfarin
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Updated: Feb 19, 2026
The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation
Published on: February 28, 2012
Dragos Vinereanu1, Renato D Lopes2, Hillary Mulder2
1From the University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital, Bucharest, Romania (D.V.); Duke Clinical Research Institute (C.B.G., J.H.A.), Duke University School of Medicine, Durham, NC (R.D.L., H.M.); Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN (B.J.G.); Bristol-Myers Squibb, Princeton, NJ (M.H.); Brazilian Clinical Research Institute, São Paulo, Brazil (P.G.M.d.B.e.S.); Oslo University Hospital, Norway (D.A.); and Uppsala Clinical Research Institute, Uppsala University, Sweden (L.W.). vinereanu@gmail.com.
Insights
In atrial fibrillation patients on anticoagulation, common echocardiographic findings like spontaneous echo contrast (SEC) and complex aortic plaque (CAP) did not increase thromboembolic event risk. Apixaban and warfarin showed similar efficacy and safety profiles for these conditions.
Area of Science:
- Cardiology
- Echocardiography
- Clinical Outcomes
Background:
- Limited data exist on long-term outcomes for atrial fibrillation patients with spontaneous echo contrast (SEC), left atrial/left atrial appendage (LA/LAA) thrombus, or complex aortic plaque (CAP) on oral anticoagulation.
- These echocardiographic findings are potential indicators of thromboembolic risk, but their impact in patients receiving anticoagulation is not well-defined.
Purpose of the Study:
- To investigate the relationship between SEC, LA/LAA thrombus, and CAP and clinical outcomes in atrial fibrillation patients.
- To compare the efficacy and safety of apixaban versus warfarin in patients with these echocardiographic findings.
Main Methods:
- Analysis of data from the ARISTOTLE trial, comparing patients with SEC, LA/LAA thrombus, or CAP to those without these findings.
- Echocardiographic diagnoses were made using transthoracic or transesophageal echocardiography.
Main Results:
- No significant difference in stroke/systemic embolism rates was observed between patients with and without SEC, LA/LAA thrombus, or CAP.
- Ischemic stroke, myocardial infarction, cardiovascular death, and all-cause death rates were similar across groups.
- Apixaban and warfarin showed comparable efficacy and safety, except for a potential greater benefit of apixaban in reducing all-cause death and bleeding in patients without LA/LAA thrombus.
Conclusions:
- In anticoagulated atrial fibrillation patients with stroke risk factors, the presence of SEC, LA/LAA thrombus, or CAP does not appear to increase the risk of thromboembolic events.
- Echocardiographic findings alone may not necessitate changes in anticoagulation strategy in this patient population.
Background And Purpose:
Few data exist on the long-term outcomes of patients with spontaneous echo contrast (SEC), left atrial/left atrial appendage (LA/LAA) thrombus, and complex aortic plaque (CAP), in patients with atrial fibrillation receiving oral anticoagulation. We explored the relationship between these 3 echocardiographic findings and clinical outcomes, and the comparative efficacy and safety of apixaban and warfarin for each finding.
Methods:
Patients from the ARISTOTLE trial (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) with SEC, LA/LAA thrombus, or CAP diagnosed by either transthoracic or transesophageal echocardiography were compared with patients with none of these findings on transesophageal echocardiography.
Results:
A total of 1251 patients were included: 217 had SEC, 127 had LA/LAA thrombus, 241 had CAP, and 746 had none. The rates of stroke/systemic embolism were not significantly different among patients with and without these echocardiographic findings (hazard ratio, 0.96; 95% confidence interval, 0.25-3.60 for SEC; hazard ratio, 1.27; 95% confidence interval, 0.23-6.86 for LA/LAA thrombus; hazard ratio, 2.21; 95% confidence interval, 0.71-6.85 for CAP). Rates of ischemic stroke, myocardial infarction, cardiovascular death, and all-cause death were also not different between patients with and without these findings. For patients with either SEC or CAP, there was no evidence of a differential effect of apixaban over warfarin. For patients with LA/LAA thrombus, there was also no significant interaction, with the exception of all-cause death and any bleeding where there was a greater benefit of apixaban compared with warfarin among patients with no LA/LAA thrombus.
Conclusions:
In anticoagulated patients with atrial fibrillation and risk factors for stroke, echocardiographic findings do not seem to add to the risk of thromboembolic events.
Clinical Trial Registration:
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00412984.
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