Risk of thromboembolism in new onset or transient atrial fibrillation

Atrial fibrillation (AF), potentially serious cardiac arrhythmia, occurs in 2% to 4% of persons greater than 60 years of age. The risk of systemic thromboembolism from chronic AF has long been recognized. Little is known about the thromboembolic risk of new onset AF. However, the results of prior studies support a significant risk of thromboembolism because of recent onset or paroxysmal AF. The mechanism of thrombus formation, embolization, and resolution in AF is ill-defined, particularly that of new onset. The traditional concept holds that atrial thrombus forms only after greater than 2 days of AF and embolizes by dislodgement from increases in shear forces. This prevailing concept further proposes that newly formed atrial thrombus, in the setting of AF, organizes over a span of 14 days. The results of recent transesophageal echocardiographic studies have given insight into the temporal sequence of atrial thrombus formation, embolization, and resolution in AF and have expanded the traditional concept of thromboembolism in AF. Namely, left atrial thrombus may form before the onset of AF in the face of sinus rhythm. Conversion to sinus rhythm may increase the thrombogenic millieu of the left atrium. Importantly, atrial thrombus may form in the acute phase of AF. Lastly, thrombus may require more than 14 days to become immobile or to resolve. On the basis of these emerging insights by transesophageal echocardiography, it appears appropriate to consider anticoagulation in patients presenting with new onset or acute AF.