Risk of left atrial appendage thrombus in patients with atrial fibrillation and chronic kidney disease

Abstract

Background: Atrial fibrillation (AF) and chronic kidney disease (CKD) are associated with an increased risk of ischemic stroke. The aim of this study was to compare the clinical characteristics, the incidence of left atrial appendage (LAA) thrombus and its predictors, and spontaneous echo contrast (SEC) in a population of patients with AF depending on estimated glomerular filtration rate (eGFR) values. Methods: This study included 1962 patients who underwent transesophageal echocardiographic examination (TEE) prior to cardioversion or ablation in the years 2014-2018 in three cardiac centers. Results: More than a quarter of AF patients had decreased eGFR (< 60 mL/min/1.73 m 2) and were characterized as a high-risk population, with more comorbidities, higher thromboembolic and bleeding risk compared to those with normal renal function. Oral anticoagulation (OAC) was prescribed in 97% and 93% of patients with decreased and normal eGFR, respectively, with a higher prevalence of prescribed non-vitamin K antagonist oral anticoagulants (NOACs). The incidence of LAA thrombus (24%, 9% and 4%) and SEC (25%, 25% and 19%) increases simultaneously with a decrease in eGFR (< 30, 30-59 and > 60 mL/min/1.73 m 2 , respectively). Among patients prescribed reduced doses of NOAC, those with decreased eGFR were more often observed with LAA thrombus (10% vs. 2.5%). Non-paroxysmal AF, heart failure and previous bleeding were predictors of LAA thrombus, irrespective of eGFR value. CKD was the predictor of LAA thrombus in all patients including those with non-paroxysmal AF, males, without diabetes, without hypertension and with CHA2DS2-VASc < 2. Conclusions: Despite OAC, patients with concomitant AF and CKD remain at high risk for LAA thrombus formation.

Decreased left atrial appendage emptying velocity as a link between atrial fibrillation type, heart failure and older age and the risk of left atrial thrombus in atrial fibrillation

“…In the academic department, all patients have TEE performed routinely before direct current cardioversion of AF or catheter ablation for AF (pulmonary vein isolation) excluding those admitted for cardioversion for emergency indications, as described previously 2,6 . In the military hospital, preprocedural TEE was performed in case of any doubt regarding the efficacy of oral anticoagulation (OAC) or patient's compliance 7,8 . In both departments, TEE was conducted within 48 hours prior to the scheduled procedure (usually directly or a few hours before the procedure).…”

Left Atrial Thrombus in Atrial Fibrillation/Flutter Patients in Relation to Anticoagulation Strategy: LATTEE Registry

“…Although neither the 2020 guidelines of the European Society of Cardiology [ 4 ] nor the 2021 European Heart Rhythm Association practical guide on the use of NOACs [ 16 ] provide clear recommendations on the choice of NOAC in specific clinical situations, in our real-life AF/AFl population, we observed a preference for apixaban in patients with the highest bleeding risk and the worst renal function (and a preference for rivaroxaban and dabigatran in those with the lowest bleeding risk, with VKA prescribed in the “intermediate” group): patients on apixaban were the oldest (median age: 71 years vs. 68 years on VKA vs. ~66 years on rivaroxaban and dabigatran), more often had a history of previous bleeding (7.0% vs. 3.5% on VKA and ~3% on rivaroxaban and dabigatran) or anemia (19% vs. 22% on VKA vs. 12% on rivaroxaban and 15% on dabigatran) and more often had GFR < 50 mL/min (18% vs. 15% on VKA vs. ~8% on rivaroxaban and dabigatran). At the same time, patients on apixaban had the highest thromboembolic risk determined by both the highest median CHA 2 DS 2 -VASc score (4 vs. 3 on VKA, rivaroxaban and dabigatran) and the worst renal function [ 17 , 18 ]. This, together with more frequent prescription of reduced doses, could account for the higher prevalence of LA thrombus in apixaban-treated patients compared to rivaroxaban- and dabigatran-treated patients.…”

Differences in the predictors of left atrial appendage thrombus between men and women treated with dabigatran or rivaroxaban

“…Advanced kidney disease was associated with a higher risk of stroke, death, and bleeding. Some studies identified renal dysfunction to be an important predictor of LAAT, enhancing the prognostic value of the CHA2DS-VASc score [2,3]. Impaired renal function was a predictor of LAAT only in men.…”

“…The CHADS2 and CHA2DS2-VASc scores are used for the assessment of thromboembolic risk in patients with nonvalvular AF. The CHA2DS2-VASc-RAF score additionally included the type of AF and renal dysfunction as LAAT predictors, which appeared to improve thromboembolic risk stratification [2][3][4]. Despite optimal treatment with vitamin K antagonists and the currently preferred non-vitamin K oral antagonists (NOACs), LAAT still develops in 2% to 10% of patients on anticoagulant treatment [5][6][7][8].…”