International Journal of Cardiology 184 (2015) 540–542
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
High CHA2DS2−VASc score predicts left atrial thrombus or spontaneous echo contrast detected by transesophageal echocardiography Enyuan Zhang, Tong Liu, Zhenyu Li, Jianping Zhao, Guangping Li ⁎ Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, People's Republic of China
a r t i c l e
i n f o
Article history: Received 17 January 2015 Accepted 27 February 2015 Available online 28 February 2015 Keywords: CHA2DS2-VASc score Left atrial thrombus Spontaneous echo contrast Transesophageal echocardiography Meta-analysis
CHA2DS2-VASc score alone has been reported to predict 30-day risk of stroke reliably [1]. A CHA2DS2-VASc score of 0 could relatively precisely prompt truly low incidence of stroke, with an annual ischemic stroke rate of approximately 1% [2]. Besides definite echocardiographic image of left atrial thrombus (LATH), the presence of left atrial spontaneous echocardiographic contrast (LASEC) has also been widely and early used to represent severe blood stasis in left atrium or even potential LATH and high risk of thromboembolic events [3,4]. In recent years, several studies have evaluated the efficiency of CHA2DS2-VASc score for predicting left LATH or LASEC, a potential symbol of ischemic stroke. CHA2DS2-VASc was an independent risk factor of LATH in some researches [5–7], while losing predictive value in some other studies [8–10]. Hence, we performed this meta-analysis aiming to determine whether CHA2DS2-VASc score has the ability to predict the presence of LA thrombus in patients with atrial fibrillation (AF). The CHADS2 scoring scheme has been considered a validated predictor for risk of stroke and once enrolled in AF guidelines [11]. While, novel risk factor-based approach named CHA2DS2-VASc was issued in the guidelines for the management of non-valvular AF by European Society of Cardiology, which was modified from CHADS2 scoring and included congestive heart failure, hypertension, age (1 point for age 65–74 and 2 points for age N 75), diabetes mellitus, stroke or transient ischaemic attack (assigned for 2 points), vascular disease (myocardial infarction, complex aortic plaque, prior revascularization, amputation ⁎ Corresponding author. E-mail address: [email protected] (G. Li).
http://dx.doi.org/10.1016/j.ijcard.2015.02.109 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
due to peripheral arterial diseases, angiographic evidence of peripheral arterial diseases, etc.), and sex category (female) [12]. Compared to the previous scoring method, CHA2DS2-VASc contains three additional factors: age stratification, female gender, and vascular disease, making it more individualized and comprehensive. The effective clinical predictor CHA2DS2-VASc score scheme was reported in these studies to estimate the incidence of LATH or LATH/LASEC in patients with AF [11]. Our search identified 6 reports [5–10] enrolling a total of 2594 patients with AF. The investigator, publication year, total number of patients, definition of left atrial thrombus, cohort study design, and risk estimate method are summarized in Table 1. Table 2 presented the detailed information of patients from separate studies, which include the basic condition, simultaneous diseases, parameters of echocardiography, and AF type. The pooled analysis of 6 studies demonstrated a statistically significant 70% increase in detection of LATH/LASEC with higher CHA2DS2-VASc score to lower CHA2DS2-VASc score in the randomeffects model (OR, 1.70; 95% confidence interval [CI], 1.16–2.48; P = 0.006; Fig. 1). When further dividing the outcome into more accurate LATH/LASEC or only LATH, the results remained that higher CHA2DS2VASc score, as continuous variable, increased 122% risk for detecting LATH(OR, 2.22; 95% CI, 1.11–4.44; P = 0.02; Fig. 2). There was maximal trial heterogeneity and accordingly great difference in the pooled results from random-effects modeling. Removing of any single study could not substantively alter the overall results of our meta-analysis. Sensitivity analysis showed only when the study from Uz [7] was excluded, which contained the patients with advanced mean age (70.1 years), largest proportion of female (51.1%), maximal diabetes mellitus (33.0%) and hypertension prevalence (80.9%), the Table 1 Characteristics of studies included in meta-analysis. Investigator Publication Patients Definition of left year (n) atrial thrombus
Cohort study design
Liu Deftereos
2014 2011
525 86
Retrospective aOR Retrospective aOR
Sugiura
2012
225
Tang Zhao Uz
2014 2014 2014
1359 90 309
LATH/SEC LATH and/or LAA thrombi LATH after 3-month warfarin LATH LATH/SEC LATH
Prospective
Risk estimate
aOR
Retrospective aOR Retrospective OR Retrospective aOR
LATH = left atrial thrombus; SEC = spontaneous echo contrast; LAA = left atrial appendage; aOR = adjusted odd ratio; N/A = not applicable.
E. Zhang et al. / International Journal of Cardiology 184 (2015) 540–542
541
Table 2 Baseline clinical characteristics of included studies. Investigator
Publication year
PAF (%)
LATH or SEC (%)
Age (years)
Male (%)
LAD (mm)
LVEF (%)
DM (%)
HTN (%)
CHA2DS2-VASc
Liu Deftereos Sugiura Tang Zhao Uz
2014 2011 2012 2014 2014 2014
83.0 N/A 66.2 65.1 56.7 N/A
10.9 43.0 10.2⁎ 8.2 27.3 22.7
60.8 62.2 62.0 58.2 60.1 70.1
64.2 65.1 76.9 70.8 60.0 48.9
37.9 42.0 40.0 39.0 40.4 N/A
N/A 60.0 64.0 63.4 57.7 N/A
N/A 23.3 13.3 13.4 17.8 33.0
N/A 50.0 55.6 51.7 52.2 80.9
N/A 1.7 2.1 N/A 2.5 N/A
PAF = paroxysmal atrial fibrillation; LATH = left atrial thrombus; SEC = spontaneous echo contrast; LAD = left atrium diameter; LVEF = left ventricle ejection fraction; DM = diabetes mellitus; HTN = hypertension; N/A = not applicable; CHA2DS2-VASc = congestive heart failure, hypertension, age N 75 years, diabetes mellitus, stroke, vascular disease, age 65 to 74 years, sex category. ⁎ Showed only the proportion of LATH.
heterogeneity among individual studies decreased significantly. To assess publication bias we generated a funnel plot (Fig. 3). Our study supported that the prevalence of LATH/LASEC increased with the elevation of CHA2DS2-VASc scores. Prior study reported that the prevalence of LATH was 10.3% in all patients with non-valvular atrial fibrillation (AF) before direct current cardioversion and the presence of LATH was universally accepted as prognostication of increased annual incidence of stroke or systemic embolus [13]. Several studies [14,15] have proved that application of the CHA2DS2VASc score instead of CHADS2 could increase the sensitivity for detecting risk factors from transesophageal echocardiography (TEE), while decrease the specificity. The referred new scoring system had been frequently reported related to high embolic risk by TEE findings, such as LATH and LASEC [16]. Absolute condition was also reached that none of the patients with a CHA2DS2-VASc score of 0 was detected LATH [17] or related with the presence of stroke [18]. A growing body of evidence has certified the link between some components of the score system and LA thrombus, including congestive heart failure, recent embolic history [19], and even female gender, which was regarded as a risk factor for stroke incidence among AF patients [20]. The other components
of CHA2DS2-VASc score including diabetes mellitus, vessel diseases, hypertension and elderly were not predictors of LA thrombus or just lack of definitive studies. Guidelines for the management of AF published in 2012 recommend anti-coagulation for patients with a CHA2DS2VASc score ≥ 1 [21]. Besides those, compared with CHADS 2 score, CHA2DS2-VASc score further amplifies the predictive value of the presence of LATH in AF patients, especially for those at low and intermediate risk categories for stroke [22–24]. Although CHADS2 scores was found higher with the increasing of LATH/LASEC incidence [25], Keogh et al. [26] have suspected the efficacy of CHADS2 in predicting ischemic stroke across disparate risk stratification in a previous meta-analysis. In conclusion, high CHA2DS2-VASc score was independently associated with the presence of LATH/LASEC in patients with non-valvular AF.
Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
Fig. 1. Forest plot of association between high CHA2DS2-VASc score and LATH/LASEC detected by TEE.
Fig. 2. Forest plot of association between high CHA2DS2-VASc score and LATH detected by TEE.
542
E. Zhang et al. / International Journal of Cardiology 184 (2015) 540–542
Fig. 3. Funnel plot of the meta-analysis. LATH = left atrial thrombus; LASEC = left atrial spontaneous echo contrast; TEE = transesophageal echocardiography.
References [1] T.S. Potpara, M.M. Polovina, D. Djikic, J.M. Marinkovic, N. Kocev, G.Y. Lip, The association of CHA2DS2-VASc score and blood biomarkers with ischemic stroke outcomes: the Belgrade stroke study, PLoS One 9 (9) (2014) e106439. [2] T.F. Chao, C.J. Liu, K.L. Wang, Y.J. Lin, S.L. Chang, L.W. Lo, et al., Using the CHA2DS2VASc score for refining stroke risk stratification in ‘low-risk’ Asian patients with atrial fibrillation, J. Am. Coll. Cardiol. 64 (16) (2014) 1658–1665. [3] D. Fatkin, R.P. Kelly, M.P. Feneley, Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast and thromboembolic risk in vivo, J. Am. Coll. Cardiol. 23 (4) (1994) 961–969. [4] W.G. Daniel, U. Nellessen, E. Schröder, B. Nonnast-Daniel, P. Bednarski, P. Nikutta, et al., Left atrial spontaneous echo contrast in mitral valve disease: an indicator for an increased thromboembolic risk, J. Am. Coll. Cardiol. 11 (6) (1988) 1204–1211. [5] S. Deftereos, G. Giannopoulos, C. Kossyvakis, K. Raisakis, A. Kaoukis, C. Aggeli, et al., Estimation of atrial fibrillation recency of onset and safety of cardioversion using NTproBNP levels in patients with unknown time of onset, Heart 97 (11) (2011) 914–917. [6] F.Z. Liu, W. Wei, Y.M. Xue, X.Z. Zhan, X.H. Fang, H.T. Liao, Predictive value of serum uric acid level for left atrial thrombus or spontaneous echo contrast in patients with atrial fibrillation, JACCon 64 (16) (2014) C235. [7] O. Uz, M. Atalay, M. Doğan, Z. Isilak, M. Yalcin, M. Uzun, et al., The CHA2DS2-VASc score as a predictor of left atrial thrombus in patients with non-valvular atrial fibrillation, Med. Princ. Pract. 23 (3) (2014) 234–238. [8] S. Sugiura, E. Fujii, M. Senga, E. Sugiura, M. Nakamura, M. Ito, Clinical features of patients with left atrial thrombus undergoing anticoagulant therapy, J. Interv. Card. Electrophysiol. 34 (1) (2012) 59–63. [9] Tang Rb, J.Z. Dong, X.L. Yan, X. Du, J.P. Kang, J.H. Wu, et al., Serum uric acid and risk of left atrial thrombus in patients with nonvalvular atrial fibrillation, Can. J. Cardiol. 30 (2014) 1415–1421. [10] J. Zhao, T. Liu, P. Korantzopoulos, H. Fu, Q. Shao, Y. Suo, et al., Red blood cell distribution width and left atrial thrombus or spontaneous echo contrast in patients with non-valvular atrial fibrillation, Int. J. Cardiol. 180 (2015) 63–65.
[11] European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery, A.J. Camm, P. Kirchhof, G.Y. Lip, U. Schotten, et al., Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC), EP 12 (2010) 1360–1420. [12] G.Y. Lip, R. Nieuwlaat, R. Pisters, D.A. Lane, H.J. Crijns, Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation, Chest 137 (2010) 263–272. [13] M. Coppens, J.W. Eikelboom, R.G. Hart, S. Yusuf, G.Y. Lip, P. Dorian, et al., The CHA2DS2-VASc score identifies those patients with atrial fibrillation and a CHADS 2 score of 1 who are unlikely to benefit from oral anticoagulant therapy, Eur. Heart J. 34 (2013) 170–176. [14] T. Sá, J. Sargento-Freitas, V. Pinhero, R. Martins, R. Teixeira, F. Silva, et al., CHADS(2) and CHA2DS2-VASc scores as predictors of cardioembolic sources in secondary stroke prevention, Rev. Port. Cardiol. 32 (2013) 373–378. [15] H.J. Willens, O. Gomez-Marin, K. Nelson, A. DeNicco, M. Moscucci, Correlation of CHADS 2 and CHA2DS2-VASc scores with transesophageal echocardiography risk factors of thromboembolism in a multiethnic United States population with nonvalvular atrial fibrillation, J. Am. Soc. Echocardiogr. 26 (2013) 175–184. [16] M.G. Parikh, Z. Aziz, K. Krishnan, C. Madias, R.G. Trohman, Usefulness of transesophageal echocardiography to confirm clinical utility of CHA2DS2-VASc and CHADS 2 scores in atrial flutter, Am. J. Cardiol. 109 (2012) 550–555. [17] R.B. Tang, J.Z. Dong, X.P. Liu, D.Y. Long, R.H. Yu, X. Du, et al., Is CHA2DS2-VASc score a predictor of left atrial thrombus in patients with paroxysmal atrial fibrillation? Thromb. Haemost. 105 (2011) 1107–1109. [18] T.S. Potpara, M.M. Polovina, M.M. Licina, J.M. Marinkovic, M.S. Prostran, G.Y. Lip, Reliable identification of ‘truly low’ thromboembolic risk in patients initially diagnosed with ‘lone’ atrial fibrillation: the Belgrade atrial fibrillation study, Circ. Arrhythm. Electrophysiol. 2 (2012) 319–326. [19] T. Kleemann, T. Becker, M. Strauss, S. Schneider, K. Seidl, Prevalence and clinical impact of left atrial thrombus and dense spontaneous echo contrast in patients with atrial fibrillation and low CHADS2 score, Eur. J. Echocardiogr. 10 (2009) 383–388. [20] D. Poli, E. Antonucci, E. Grifoni, R. Abbate, G.F. Gensini, D. Prisco, Gender differences in stroke risk of atrial fibrillation patients on oral anticoagulant treatment, Thromb. Haemost. 101 (2009) 938–942. [21] A.J. Camm, G.Y. Lip, R. De Caterina, I. Savelieva, D. Atar, S.H. Hohnloser, et al., 2012 focused update of the ESC guidelines for the management of atrial fibrillation, Europace 12 (2012) 1385–1413. [22] H. Yarmohammadi, B.C. Varr, S. Puwanant, E. Lieber, S.J. Williams, T. Klostermann, et al., Role of CHADS 2 score in evaluation of thromboembolic risk and mortality in patients with atrial fibrillation undergoing direct current cardioversion (from the ACUTE Trial Substudy), Am. J. Cardiol. 110 (2012) 222–226. [23] K. Wasmer, J. Kobe, D. Dechering, P. Milberg, C. Pott, J. Vogler, et al., CHADS(2) and CHA(2)DS(2)-VASc score of patients with atrial fibrillation or flutter and newly detected left atrial thrombus, Clin. Res. Cardiol. 102 (2013) 139–144. [24] J.B. Olesen, C. Torp-Pedersen, M.L. Hansen, G.Y. Lip, The value of the CHA2DS2-VASc score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS 2 score 0–1: a nationwide cohort, Thromb. Haemost. 207 (6) (2012) 1172–1179. [25] T. Maehama, H. Okura, K. İmai, R. Yamada, K. Obase, K. Saito, et al., Usefulness of CHADS 2 score to predict C-reactive protein, left atrial blood stasis, and prognosis in patients with nonrheumatic atrial fibrillation, Am. J. Cardiol. 106 (2010) 535–553. [26] C. Keogh, E. Wallace, C. Dillon, B.D. Dimitrov, T. Fahey, Validation of the CHADS 2 clinical prediction rule to predict ischaemic stroke: a systematic review and metaanalysis, Thromb. Haemost. (2011) 528–538.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
High CHA2DS2−VASc score predicts left atrial thrombus or spontaneous echo contrast detected by transesophageal echocardiography Enyuan Zhang, Tong Liu, Zhenyu Li, Jianping Zhao, Guangping Li ⁎ Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, People's Republic of China
a r t i c l e
i n f o
Article history: Received 17 January 2015 Accepted 27 February 2015 Available online 28 February 2015 Keywords: CHA2DS2-VASc score Left atrial thrombus Spontaneous echo contrast Transesophageal echocardiography Meta-analysis
CHA2DS2-VASc score alone has been reported to predict 30-day risk of stroke reliably [1]. A CHA2DS2-VASc score of 0 could relatively precisely prompt truly low incidence of stroke, with an annual ischemic stroke rate of approximately 1% [2]. Besides definite echocardiographic image of left atrial thrombus (LATH), the presence of left atrial spontaneous echocardiographic contrast (LASEC) has also been widely and early used to represent severe blood stasis in left atrium or even potential LATH and high risk of thromboembolic events [3,4]. In recent years, several studies have evaluated the efficiency of CHA2DS2-VASc score for predicting left LATH or LASEC, a potential symbol of ischemic stroke. CHA2DS2-VASc was an independent risk factor of LATH in some researches [5–7], while losing predictive value in some other studies [8–10]. Hence, we performed this meta-analysis aiming to determine whether CHA2DS2-VASc score has the ability to predict the presence of LA thrombus in patients with atrial fibrillation (AF). The CHADS2 scoring scheme has been considered a validated predictor for risk of stroke and once enrolled in AF guidelines [11]. While, novel risk factor-based approach named CHA2DS2-VASc was issued in the guidelines for the management of non-valvular AF by European Society of Cardiology, which was modified from CHADS2 scoring and included congestive heart failure, hypertension, age (1 point for age 65–74 and 2 points for age N 75), diabetes mellitus, stroke or transient ischaemic attack (assigned for 2 points), vascular disease (myocardial infarction, complex aortic plaque, prior revascularization, amputation ⁎ Corresponding author. E-mail address: [email protected] (G. Li).
http://dx.doi.org/10.1016/j.ijcard.2015.02.109 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
due to peripheral arterial diseases, angiographic evidence of peripheral arterial diseases, etc.), and sex category (female) [12]. Compared to the previous scoring method, CHA2DS2-VASc contains three additional factors: age stratification, female gender, and vascular disease, making it more individualized and comprehensive. The effective clinical predictor CHA2DS2-VASc score scheme was reported in these studies to estimate the incidence of LATH or LATH/LASEC in patients with AF [11]. Our search identified 6 reports [5–10] enrolling a total of 2594 patients with AF. The investigator, publication year, total number of patients, definition of left atrial thrombus, cohort study design, and risk estimate method are summarized in Table 1. Table 2 presented the detailed information of patients from separate studies, which include the basic condition, simultaneous diseases, parameters of echocardiography, and AF type. The pooled analysis of 6 studies demonstrated a statistically significant 70% increase in detection of LATH/LASEC with higher CHA2DS2-VASc score to lower CHA2DS2-VASc score in the randomeffects model (OR, 1.70; 95% confidence interval [CI], 1.16–2.48; P = 0.006; Fig. 1). When further dividing the outcome into more accurate LATH/LASEC or only LATH, the results remained that higher CHA2DS2VASc score, as continuous variable, increased 122% risk for detecting LATH(OR, 2.22; 95% CI, 1.11–4.44; P = 0.02; Fig. 2). There was maximal trial heterogeneity and accordingly great difference in the pooled results from random-effects modeling. Removing of any single study could not substantively alter the overall results of our meta-analysis. Sensitivity analysis showed only when the study from Uz [7] was excluded, which contained the patients with advanced mean age (70.1 years), largest proportion of female (51.1%), maximal diabetes mellitus (33.0%) and hypertension prevalence (80.9%), the Table 1 Characteristics of studies included in meta-analysis. Investigator Publication Patients Definition of left year (n) atrial thrombus
Cohort study design
Liu Deftereos
2014 2011
525 86
Retrospective aOR Retrospective aOR
Sugiura
2012
225
Tang Zhao Uz
2014 2014 2014
1359 90 309
LATH/SEC LATH and/or LAA thrombi LATH after 3-month warfarin LATH LATH/SEC LATH
Prospective
Risk estimate
aOR
Retrospective aOR Retrospective OR Retrospective aOR
LATH = left atrial thrombus; SEC = spontaneous echo contrast; LAA = left atrial appendage; aOR = adjusted odd ratio; N/A = not applicable.
E. Zhang et al. / International Journal of Cardiology 184 (2015) 540–542
541
Table 2 Baseline clinical characteristics of included studies. Investigator
Publication year
PAF (%)
LATH or SEC (%)
Age (years)
Male (%)
LAD (mm)
LVEF (%)
DM (%)
HTN (%)
CHA2DS2-VASc
Liu Deftereos Sugiura Tang Zhao Uz
2014 2011 2012 2014 2014 2014
83.0 N/A 66.2 65.1 56.7 N/A
10.9 43.0 10.2⁎ 8.2 27.3 22.7
60.8 62.2 62.0 58.2 60.1 70.1
64.2 65.1 76.9 70.8 60.0 48.9
37.9 42.0 40.0 39.0 40.4 N/A
N/A 60.0 64.0 63.4 57.7 N/A
N/A 23.3 13.3 13.4 17.8 33.0
N/A 50.0 55.6 51.7 52.2 80.9
N/A 1.7 2.1 N/A 2.5 N/A
PAF = paroxysmal atrial fibrillation; LATH = left atrial thrombus; SEC = spontaneous echo contrast; LAD = left atrium diameter; LVEF = left ventricle ejection fraction; DM = diabetes mellitus; HTN = hypertension; N/A = not applicable; CHA2DS2-VASc = congestive heart failure, hypertension, age N 75 years, diabetes mellitus, stroke, vascular disease, age 65 to 74 years, sex category. ⁎ Showed only the proportion of LATH.
heterogeneity among individual studies decreased significantly. To assess publication bias we generated a funnel plot (Fig. 3). Our study supported that the prevalence of LATH/LASEC increased with the elevation of CHA2DS2-VASc scores. Prior study reported that the prevalence of LATH was 10.3% in all patients with non-valvular atrial fibrillation (AF) before direct current cardioversion and the presence of LATH was universally accepted as prognostication of increased annual incidence of stroke or systemic embolus [13]. Several studies [14,15] have proved that application of the CHA2DS2VASc score instead of CHADS2 could increase the sensitivity for detecting risk factors from transesophageal echocardiography (TEE), while decrease the specificity. The referred new scoring system had been frequently reported related to high embolic risk by TEE findings, such as LATH and LASEC [16]. Absolute condition was also reached that none of the patients with a CHA2DS2-VASc score of 0 was detected LATH [17] or related with the presence of stroke [18]. A growing body of evidence has certified the link between some components of the score system and LA thrombus, including congestive heart failure, recent embolic history [19], and even female gender, which was regarded as a risk factor for stroke incidence among AF patients [20]. The other components
of CHA2DS2-VASc score including diabetes mellitus, vessel diseases, hypertension and elderly were not predictors of LA thrombus or just lack of definitive studies. Guidelines for the management of AF published in 2012 recommend anti-coagulation for patients with a CHA2DS2VASc score ≥ 1 [21]. Besides those, compared with CHADS 2 score, CHA2DS2-VASc score further amplifies the predictive value of the presence of LATH in AF patients, especially for those at low and intermediate risk categories for stroke [22–24]. Although CHADS2 scores was found higher with the increasing of LATH/LASEC incidence [25], Keogh et al. [26] have suspected the efficacy of CHADS2 in predicting ischemic stroke across disparate risk stratification in a previous meta-analysis. In conclusion, high CHA2DS2-VASc score was independently associated with the presence of LATH/LASEC in patients with non-valvular AF.
Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
Fig. 1. Forest plot of association between high CHA2DS2-VASc score and LATH/LASEC detected by TEE.
Fig. 2. Forest plot of association between high CHA2DS2-VASc score and LATH detected by TEE.
542
E. Zhang et al. / International Journal of Cardiology 184 (2015) 540–542
Fig. 3. Funnel plot of the meta-analysis. LATH = left atrial thrombus; LASEC = left atrial spontaneous echo contrast; TEE = transesophageal echocardiography.
References [1] T.S. Potpara, M.M. Polovina, D. Djikic, J.M. Marinkovic, N. Kocev, G.Y. Lip, The association of CHA2DS2-VASc score and blood biomarkers with ischemic stroke outcomes: the Belgrade stroke study, PLoS One 9 (9) (2014) e106439. [2] T.F. Chao, C.J. Liu, K.L. Wang, Y.J. Lin, S.L. Chang, L.W. Lo, et al., Using the CHA2DS2VASc score for refining stroke risk stratification in ‘low-risk’ Asian patients with atrial fibrillation, J. Am. Coll. Cardiol. 64 (16) (2014) 1658–1665. [3] D. Fatkin, R.P. Kelly, M.P. Feneley, Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast and thromboembolic risk in vivo, J. Am. Coll. Cardiol. 23 (4) (1994) 961–969. [4] W.G. Daniel, U. Nellessen, E. Schröder, B. Nonnast-Daniel, P. Bednarski, P. Nikutta, et al., Left atrial spontaneous echo contrast in mitral valve disease: an indicator for an increased thromboembolic risk, J. Am. Coll. Cardiol. 11 (6) (1988) 1204–1211. [5] S. Deftereos, G. Giannopoulos, C. Kossyvakis, K. Raisakis, A. Kaoukis, C. Aggeli, et al., Estimation of atrial fibrillation recency of onset and safety of cardioversion using NTproBNP levels in patients with unknown time of onset, Heart 97 (11) (2011) 914–917. [6] F.Z. Liu, W. Wei, Y.M. Xue, X.Z. Zhan, X.H. Fang, H.T. Liao, Predictive value of serum uric acid level for left atrial thrombus or spontaneous echo contrast in patients with atrial fibrillation, JACCon 64 (16) (2014) C235. [7] O. Uz, M. Atalay, M. Doğan, Z. Isilak, M. Yalcin, M. Uzun, et al., The CHA2DS2-VASc score as a predictor of left atrial thrombus in patients with non-valvular atrial fibrillation, Med. Princ. Pract. 23 (3) (2014) 234–238. [8] S. Sugiura, E. Fujii, M. Senga, E. Sugiura, M. Nakamura, M. Ito, Clinical features of patients with left atrial thrombus undergoing anticoagulant therapy, J. Interv. Card. Electrophysiol. 34 (1) (2012) 59–63. [9] Tang Rb, J.Z. Dong, X.L. Yan, X. Du, J.P. Kang, J.H. Wu, et al., Serum uric acid and risk of left atrial thrombus in patients with nonvalvular atrial fibrillation, Can. J. Cardiol. 30 (2014) 1415–1421. [10] J. Zhao, T. Liu, P. Korantzopoulos, H. Fu, Q. Shao, Y. Suo, et al., Red blood cell distribution width and left atrial thrombus or spontaneous echo contrast in patients with non-valvular atrial fibrillation, Int. J. Cardiol. 180 (2015) 63–65.
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