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Relation of Atrial Fibrillation and Right-Sided Cardiac Thrombus to Outcomes in Patients With Acute Pulmonary Embolism

Published:January 05, 2015DOI:https://doi.org/10.1016/j.amjcard.2014.12.049
      Atrial fibrillation (AF) can induce a hypercoagulable state in both the left and right atria. Thrombus in the right side of the heart (RHT) may lead to acute pulmonary embolism (APE). The aim of the study was to determine the prevalence of RHT and AF and to assess their impact on outcomes in patients with APE. The retrospective cohort included 1,006 patients (598 female), with a mean age of 66 ± 15 years. The primary end point was all-cause mortality. The secondary end point was incidence of complications (death, cardiogenic shock, cardiac arrest, vasopressor/inotrope treatment, or ventilatory support). Atrial fibrillation was detected in 231 patients (24%). RHT was observed in 50 patients (5%). The combination of AF and RHT was observed in 16 patients (2%). The overall mortality rate was significantly higher in patients with RHT compared with those without (32% vs 14%, respectively, odds ratio [OR] 3.0, 95% confidence interval [CI] 1.6 to 5.6, p = 0.001). The rate of complications was significantly higher in patients with RHT in comparison to those without (40% vs 22%, respectively, OR 2.4, 95% CI 1.3 to 4.4, p = 0.004). The mortality rate in patients with both AF and RHT was significantly higher in comparison to those with AF but without RHT (50% vs 20%, respectively, OR 3.86, 95% CI 1.3 to 11.2, p = 0.01). In multivariate analysis, RHT (p = 0.03) was an independent predictor of death. In conclusion, AF is a frequent co-morbidity in patients with APE, and the presence of RHT is not uncommon. Among patients with APE, the presence of RHT increases the mortality approximately threefold regardless of the presence of known AF.
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      References

        • Flegel K.M.
        When atrial fibrillation occurs with pulmonary embolism, is it the chicken or the eggs ?.
        CMAJ. 1999; 160: 1181-1182
        • Black I.W.
        • Hopkins A.P.
        • Lee L.C.L.
        • Walsh W.F.
        Left atrial spontaneous contrast echo: a clinical and echocardiographic analysis.
        J Am Coll Cardiol. 1991; 18: 398-404
        • DeGeorgia M.A.
        • Chimowitz M.I.
        • Hepner A.
        • Armstrong W.F.
        Right atrial spontaneous contrast: echocardiographic and clinical features.
        Int J Card Imaging. 1994; 10: 227-232
        • Lip G.Y.H.
        Does atrial fibrillation confer a hypercoagulable state?.
        Lancet. 1995; 346: 1313-1314
        • Kahn S.R.
        • Solymoss S.
        • Flegel K.M.
        Nonvalvular atrial fibrillation: evidence for a prothrombotic state.
        CMAJ. 1997; 157: 673-681
        • Sohara H.
        • Amitani S.
        • Kurose M.
        • Miyahara K.
        Atrial fibrillation activates platelets and coagulation in a time-dependent manner: a study in patients with paroxysmal atrial fibrillation.
        J Am Coll Cardiol. 1997; 29: 106-112
        • Aberg H.
        Atrial fibrillation. I: a study of atrial thrombosis and systemic embolism in a necropsy material.
        Acta Med Scand. 1969; 185: 373-379
        • Kukla P.
        • McIntyre W.F.
        • Fijorek K.
        • Długopolski R.
        • Mirek-Bryniarska E.
        • Bryniarski K.L.
        • Jastrzębski M.
        • Bryniarski L.
        • Baranchuk A.
        T-wave inversion in patients with acute pulmonary embolism: prognostic value.
        Heart Lung. 2015; 44: 68-71
        • Kukla P.
        • McIntyre W.F.
        • Fijorek K.
        • Mirek-Bryniarska E.
        • Bryniarski L.
        • Krupa E.
        • Jastrzębski M.
        • Bryniarski K.L.
        • Zhong-qun Z.
        • Baranchuk A.
        Electrocardiographic abnormalities in patients with acute pulmonary embolism complicated by cardiogenic shock.
        Am J Emerg Med. 2014; 32: 507-510
        • Kukla P.
        • McIntyre W.F.
        • Fijorek K.
        • Krupa E.
        • Mirek-Bryniarska E.
        • Jastrzębski M.
        • Bryniarski K.L.
        • Zajchowski W.
        • Bryniarski L.
        • Baranchuk A.
        Ischemic electrocardiographic patterns as prognosticators in intermediate-risk patients with acute pulmonary embolism.
        Am J Emerg Med. 2014; 32: 1248-1252
        • van Buuren S.
        • Groothuis-Oudshoorn K.
        MICE: multivariate imputation by chained equations in R.
        J Stat Softw. 2011; 45: 1-67
        • Konstantinides S.V.
        • Torbicki A.
        • Agnelli G.
        • Danchin N.
        • Fitzmaurice D.
        • Galiè N.
        • Gibbs J.S.
        • Huisman M.V.
        • Humbert M.
        • Kucher N.
        • Lang I.
        • Lankeit M.
        • Lekakis J.
        • Maack C.
        • Mayer E.
        • Meneveau N.
        • Perrier A.
        • Pruszczyk P.
        • Rasmussen L.H.
        • Schindler T.H.
        • Svitil P.
        • Vonk Noordegraaf A.
        • Zamorano J.L.
        • Zompatori M.
        • Authors/Task Force Members
        Authors/Task Force Members. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) Endorsed by the European Respiratory Society (ERS).
        Eur Heart J. 2014; (pii: ehu283)
        • Bashir M.
        • Asher C.R.
        • Garcia M.J.
        • Abdalla I.
        • Jasper S.E.
        • Murray R.D.
        • Grimm R.A.
        • Thomas J.D.
        • Klein A.L.
        Right atrial spontaneous echo contrast and thrombi in atrial fibrillation: a transesophageal echocardiography study.
        J Am Soc Echocardiogr. 2001; 14: 122-127
        • Gex G.
        • Gerstel E.
        • Righini M.
        • LE Gal G.
        • Aujesky D.
        • Roy P.M.
        • Sanchez O.
        • Verschuren F.
        • Rutschmann O.T.
        • Perneger T.
        • Perrier A.
        Is atrial fibrillation associated with pulmonary embolism?.
        J Thromb Haemost. 2012; 10: 347-351
        • Torbicki A.
        • Galie N.
        • Covezzoli A.
        • Rossi E.
        • De Rosa M.
        • Goldhaber S.Z.
        Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry.
        J Am Coll Cardiol. 2003; 41: 2245-2251
        • Casazza F.
        • Bongarzoni A.
        • Centonze F.
        • Morpurgo M.
        Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism.
        Am J Cardiol. 1997; 79: 1433-1435
        • Chartier L.
        • Bera J.
        • Delomez M.
        • Asseman P.
        • Beregi J.P.
        • Bauchart J.J.
        • Warembourg H.
        • Thery C.
        Free-floating thrombi in the right heart: diagnosis, management, and prognostic indexes in 38 consecutive patients.
        Circulation. 1999; 99: 2779-2783
        • Chapoutot L.
        • Nazeyrollas P.
        • Metz D.
        • Maes D.
        • Maillier B.
        • Jennesseaux C.
        • Elaerts J.
        Floating right heart thrombi and pulmonary embolism: diagnosis, outcome and therapeutic management.
        Cardiology. 1996; 87: 169-174
        • Mansencal N.
        • Attias D.
        • Caille V.
        • Desperramons J.
        • Guiader J.
        • El Hajjam M.
        • Lacombe P.
        • Abi Nasr I.
        • Jardin F.
        • Vieillard-Baron A.
        • Dubourg O.
        Computed tomography for the detection of free-floating thrombi in the right heart in acute pulmonary embolism.
        Eur Radiol. 2011; 21: 240-245
        • Casazza F.
        • Becattini C.
        • Guglielmelli E.
        • Floriani I.
        • Morrone V.
        • Caponi C.
        • Pizzorno N.
        • Masotti L.
        • Bongarzoni A.
        • Pignataro L.
        Prognostic significance of free-floating right heart thromboemboli in acute pulmonary embolism: results from the Italian Pulmonary Embolism Registry.
        Thromb Haemost. 2014; 111: 53-57