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Meta-Analysis
. 2021 Jun 15;77(23):2875-2886.
doi: 10.1016/j.jacc.2021.04.036.

Prevalence of Left Atrial Thrombus in Anticoagulated Patients With Atrial Fibrillation

Antony Lurie  1 , Jia Wang  2 , Kyra J Hinnegan  3 , William F McIntyre  2 , Emilie P Belley-Côté  4 , Guy Amit  5 , Jeff S Healey  4 , Stuart J Connolly  4 , Jorge A Wong  6
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Free article
Meta-Analysis

Prevalence of Left Atrial Thrombus in Anticoagulated Patients With Atrial Fibrillation

Antony Lurie et al. J Am Coll Cardiol. .
Free article

Abstract

Background: The prevalence of left atrial (LA) thrombus in patients with atrial fibrillation (AF) or atrial flutter (AFL) on guideline-directed anticoagulation is not well known, yet this may inform transesophageal echocardiogram (TEE) use before cardioversion or catheter ablation.

Objectives: The purpose of this study was to quantify LA thrombus prevalence among patients with AF/AFL on guideline-directed anticoagulation and to identify high-risk subgroups.

Methods: EMBASE, MEDLINE, and CENTRAL were systematically searched from inception to July 2020 for studies reporting on LA thrombus prevalence among patients with AF/AFL undergoing TEE following at least 3 weeks of continuous therapeutic oral anticoagulation with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). Meta-analysis was performed using random effects models.

Results: Thirty-five studies describing 14,653 patients were identified. The mean-weighted LA thrombus prevalence was 2.73% (95% confidence interval [CI]: 1.95% to 3.80%). LA thrombus prevalence was similar for VKA- and DOAC-treated patients (2.80%; 95% CI: 1.86% to 4.21% vs. 3.12%; 95% CI: 1.92% to 5.03%; p = 0.674). Patients with nonparoxysmal AF/AFL had a 4-fold higher LA thrombus prevalence compared with paroxysmal patients (4.81%; 95% CI: 3.35% to 6.86% vs. 1.03%; 95% CI: 0.52% to 2.03%; p < 0.001). LA thrombus prevalence was higher among patients undergoing cardioversion versus ablation (5.55%; 95% CI: 3.15% to 9.58% vs. 1.65%; 95% CI: 1.07% to 2.53%; p < 0.001). Patients with CHA2DS2-VASc scores ≥3 had a higher LA thrombus prevalence compared with patients with scores ≤2 (6.31%; 95% CI: 3.72% to 10.49% vs. 1.06%; 95% CI: 0.45% to 2.49%; p < 0.001).

Conclusions: LA thrombus prevalence is high in subgroups of anticoagulated patients with AF/AFL, who may benefit from routine pre-procedural TEE use before cardioversion or catheter ablation.

Keywords: anticoagulation; atrial fibrillation; cardioversion; catheter ablation; left atrial thrombus; prevalence; transesophageal echocardiography.

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Conflict of interest statement

Funding Support and Author Disclosures Dr. Wong holds a McMaster University Department of Medicine Early-Career Research Award. Dr. Healey holds the Stuart Connolly Chair in Cardiology Research at the Population Health Research Institute, and the Salim Yusuf Chair at Hamilton Health Sciences. All the authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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