48 th Annual New York Cardiovascular Symposium Thromboembolism During Sinus Rhythm in Patients with a History of Atrial Fibrillation Is Left Atrial Appendage Dysfunction Sufficient to Generate Clots? December 13, 2015 Jonathan L. Halperin, M.D. The Cardiovascular Institute Mount Sinai Medical Center
Disclosure Relationships with Industry Consultant to the following companies involved in developing anticoagulant drugs and device-based strategies for thromboembolism prevention: Bayer HealthCare Biotronik Boehringer Ingelheim Boston Scientific Bristol-Myers Squibb Daiichi Sankyo Janssen Ortho McNeil Johnson & Johnson Medtronic Pfizer
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Thromboembolism During Sinus Rhythm in Patients with a History of Atrial Fibrillation Atrial Cardiomyopathy and Stroke During NSR Trials that defined the efficacy of anticoagulation predominantly enrolled patients with persistent and permanent AF, and the benefit for patients with low AF burdens has been less well explored. Current guidelines recommend continuing anticoagulation for patients with stroke risk factors and a history of AF, even when a rhythm control strategy is employed, based on the possibility of asymptomatic recurrent AF. Interrupting anticoagulation during antiarrhythmic drug therapy of AF has been associated with increased stroke risk, but whether this applies following AF ablation is less certain.
Thromboembolism During Sinus Rhythm in Patients with a History of Atrial Fibrillation Atrial Cardiomyopathy and Stroke During NSR Paroxysmal AF may lead to thrombus formation, but appendage morphology or flow patterns might delay the occurrence of embolism. Thrombus in the LAA and other mechanisms of embolic stroke may apply in patients without AF, and the risks associated with these mechanisms also correlate with increasing CHADS 2 and CHA 2 S 2 VASc scores. An inflammatory and/or hypercoagulable state present during AF might persist and predispose to thromboembolism during periods of sinus rhythm.
Device-detected Atrial Tachyarrhythmias Insights and Caveats: The AT Burden Device-detected AT are associated with stroke, but electrograms should be evaluated to exclude artifact and verify AT. The burden of AT associated with stroke varies across studies, but averages ~5 hours over a 30 day period. Consider the AT burden in the context of clinical risk factors.
Device-detected Atrial Tachyarrhythmias Insights and Caveats: Temporal Dissociation The temporal dissociation of AT from stroke in some studies raises the possibility that AF may not be the sole cause of stroke but a marker of stroke risk. Anticoagulation should be based on comprehensive assessment of risk and benefit rather than the onset or offset of device-detected AT.