TY - JOUR
T1 - Identifying Patients at High Risk of Left Atrial Appendage Thrombus Before Cardioversion
T2 - The CLOTS-AF Score
AU - Segan, Louise
AU - Nanayakkara, Shane
AU - Spear, Ella
AU - Shirwaiker, Anita
AU - Chieng, David
AU - Prabhu, Sandeep
AU - Sugumar, Hariharan
AU - Ling, Liang Han
AU - Kaye, David M.
AU - Kalman, Jonathan M.
AU - Voskoboinik, Aleksandr
AU - Kistler, Peter M.
N1 - Funding Information:
Dr Segan is supported by a cofunded National Health and Medical Research Council/National Heart Foundation post-graduate scholarship. Professor Kistler is supported by an investigator grant from the National Health and Medical Research Council and has received funding from Abbott Medical for consultancy and speaking engagements and fellowship support from Biosense Webster. Dr Kalman has research and fellowship support from Medtronic and Biosense Webster. Dr Sandeep Prabhu has received consultancy and speaker fees from Abbott Medical and Biosense Webster. The remaining authors have no disclosures to report.
Publisher Copyright:
© 2023 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.
PY - 2023/6/20
Y1 - 2023/6/20
N2 - BACKGROUND: Transesophageal echocardiography–guided direct cardioversion is recommended in patients who are inadequately anticoagulated due to perceived risk of left atrial appendage thrombus (LAAT); however, LAAT risk factors remain poorly defined. METHODS AND RESULTS: We evaluated clinical and transthoracic echocardiographic parameters to predict LAAT risk in consecutive patients with atrial fibrillation (AF)/atrial flutter undergoing transesophageal echocardiography before cardioversion between 2002 and 2022. Regression analysis identified predictors of LAAT, combined to create the novel CLOTS-AF risk score (comprising clinical and echocardiographic LAAT predictors), which was developed in the derivation cohort (70%) and validated in the remaining 30%. A total of 1001 patients (mean age, 62±13 years; 25% women; left ventricular ejection fraction, 49.8±14%) underwent transesophageal echocardiography, with LAAT identified in 140 of 1001 patients (14%) and dense spontaneous echo contrast precluding cardioversion in a further 75 patients (7.5%). AF duration, AF rhythm, creatinine, stroke, diabetes, and echocardiographic parameters were univariate LAAT predictors; age, female sex, body mass index, anticoagulant type, and duration were not (all P>0.05). CHADS2 VASc, though significant on univariate analysis (P<0.001), was not significant after adjustment (P=0.12). The novel CLOTS-AF risk model comprised significant multivariable predictors categorized and weighted according to clinically relevant thresholds (Creatinine >1.5 mg/dL, Left ventricular ejection fraction <50%, Overload (left atrial volume index >34 mL/m2), Tricuspid Annular Plane Systolic Excursion (TAPSE) <17 mm, Stroke, and AF rhythm). The unweighted risk model had excellent predictive performance with an area under the curve of 0.820 (95% CI, 0.752–0.887). The weighted CLOTS-AF risk score maintained good predictive performance (AUC, 0.780) with an accuracy of 72%. CONCLUSIONS: The incidence of LAAT or dense spontaneous echo contrast precluding cardioversion in patients with AF who are inadequately anticoagulated is 21%. Clinical and noninvasive echocardiographic parameters may identify patients at increased risk of LAAT better managed with a suitable period of anticoagulation before undertaking cardioversion.
AB - BACKGROUND: Transesophageal echocardiography–guided direct cardioversion is recommended in patients who are inadequately anticoagulated due to perceived risk of left atrial appendage thrombus (LAAT); however, LAAT risk factors remain poorly defined. METHODS AND RESULTS: We evaluated clinical and transthoracic echocardiographic parameters to predict LAAT risk in consecutive patients with atrial fibrillation (AF)/atrial flutter undergoing transesophageal echocardiography before cardioversion between 2002 and 2022. Regression analysis identified predictors of LAAT, combined to create the novel CLOTS-AF risk score (comprising clinical and echocardiographic LAAT predictors), which was developed in the derivation cohort (70%) and validated in the remaining 30%. A total of 1001 patients (mean age, 62±13 years; 25% women; left ventricular ejection fraction, 49.8±14%) underwent transesophageal echocardiography, with LAAT identified in 140 of 1001 patients (14%) and dense spontaneous echo contrast precluding cardioversion in a further 75 patients (7.5%). AF duration, AF rhythm, creatinine, stroke, diabetes, and echocardiographic parameters were univariate LAAT predictors; age, female sex, body mass index, anticoagulant type, and duration were not (all P>0.05). CHADS2 VASc, though significant on univariate analysis (P<0.001), was not significant after adjustment (P=0.12). The novel CLOTS-AF risk model comprised significant multivariable predictors categorized and weighted according to clinically relevant thresholds (Creatinine >1.5 mg/dL, Left ventricular ejection fraction <50%, Overload (left atrial volume index >34 mL/m2), Tricuspid Annular Plane Systolic Excursion (TAPSE) <17 mm, Stroke, and AF rhythm). The unweighted risk model had excellent predictive performance with an area under the curve of 0.820 (95% CI, 0.752–0.887). The weighted CLOTS-AF risk score maintained good predictive performance (AUC, 0.780) with an accuracy of 72%. CONCLUSIONS: The incidence of LAAT or dense spontaneous echo contrast precluding cardioversion in patients with AF who are inadequately anticoagulated is 21%. Clinical and noninvasive echocardiographic parameters may identify patients at increased risk of LAAT better managed with a suitable period of anticoagulation before undertaking cardioversion.
KW - atrial fibrillation
KW - left atrial appendage thrombus
KW - risk prediction
KW - risk stratification
KW - stroke
KW - thromboembolism
KW - transesophageal echocardiography
UR - http://www.scopus.com/inward/record.url?scp=85163663824&partnerID=8YFLogxK
U2 - 10.1161/JAHA.122.029259
DO - 10.1161/JAHA.122.029259
M3 - Article
C2 - 37301743
AN - SCOPUS:85163663824
SN - 2047-9980
VL - 12
JO - Journal of the American Heart Association
JF - Journal of the American Heart Association
IS - 12
M1 - e029259
ER -