Proposal for a clinical and an echocardiographic score for prediction of left atrial thrombosis in atrial fibrillation patients undergoing early electrical cardioversion

<p>Aims: Left&nbsp;&nbsp; &nbsp;atrial&nbsp;&nbsp; &nbsp;thrombosis&nbsp;&nbsp; &nbsp;(LAT)&nbsp;&nbsp; &nbsp;is&nbsp;&nbsp; &nbsp;usually&nbsp;&nbsp; &nbsp;detected&nbsp;&nbsp; &nbsp;by&nbsp;&nbsp; &nbsp;transesophageal&nbsp;&nbsp; &nbsp;echocardi-<br> ography&nbsp;&nbsp; &nbsp;(TEE).&nbsp;&nbsp; &nbsp;The&nbsp;&nbsp; &nbsp;aim&nbsp;&nbsp; &nbsp;of&nbsp;&nbsp; &nbsp;the&nbsp;&nbsp; &nbsp;present&nbsp;&nbsp; &nbsp;study&nbsp;&nbsp; &nbsp;was&nbsp;&nbsp; &nbsp;to&nbsp;&nbsp; &nbsp;identify&nbsp;&nbsp; &nbsp;clinical&nbsp;&nbsp; &nbsp;and&nbsp;&nbsp; &nbsp;echocardio-<br> graphic&nbsp;&nbsp; &nbsp;factors&nbsp;&nbsp; &nbsp;associated&nbsp;&nbsp; &nbsp;with&nbsp;&nbsp; &nbsp;left&nbsp;&nbsp; &nbsp;atrial&nbsp;&nbsp; &nbsp;thrombosis&nbsp;&nbsp; &nbsp;in&nbsp;&nbsp; &nbsp;atrial&nbsp;&nbsp; &nbsp;fibrillation&nbsp;&nbsp; &nbsp;(AF)&nbsp;&nbsp; &nbsp;patients&nbsp;&nbsp; &nbsp;<br> undergoing&nbsp;&nbsp; &nbsp;early&nbsp;&nbsp; &nbsp;electrical&nbsp;&nbsp; &nbsp;cardioversion&nbsp;&nbsp; &nbsp;(ECV)&nbsp;&nbsp; &nbsp;in&nbsp;&nbsp; &nbsp;order&nbsp;&nbsp; &nbsp;to&nbsp;&nbsp; &nbsp;create&nbsp;&nbsp; &nbsp;scores&nbsp;&nbsp; &nbsp;that&nbsp;&nbsp; &nbsp;can&nbsp;&nbsp; &nbsp;<br> predict&nbsp;&nbsp; &nbsp;LAT,&nbsp;&nbsp; &nbsp;in&nbsp;&nbsp; &nbsp;a&nbsp;&nbsp; &nbsp;non-invasive&nbsp;&nbsp; &nbsp;way.<br> Methods: A&nbsp;&nbsp; &nbsp;consecutive&nbsp;&nbsp; &nbsp;cohort&nbsp;&nbsp; &nbsp;of&nbsp;&nbsp; &nbsp;patients&nbsp;&nbsp; &nbsp;with&nbsp;&nbsp; &nbsp;persistent&nbsp;&nbsp; &nbsp;AF&nbsp;&nbsp; &nbsp;scheduled&nbsp;&nbsp; &nbsp;for&nbsp;&nbsp; &nbsp;ECV&nbsp;&nbsp; &nbsp;<br> was&nbsp;&nbsp; &nbsp;evaluated&nbsp;&nbsp; &nbsp;by&nbsp;&nbsp; &nbsp;transthoracic&nbsp;&nbsp; &nbsp;echocardiography&nbsp;&nbsp; &nbsp;and&nbsp;&nbsp; &nbsp;TEE.&nbsp;&nbsp; &nbsp;By&nbsp;&nbsp; &nbsp;a&nbsp;&nbsp; &nbsp;logistic&nbsp;&nbsp; &nbsp;regression&nbsp;&nbsp; &nbsp;<br> model,&nbsp;&nbsp; &nbsp;variables&nbsp;&nbsp; &nbsp;significantly&nbsp;&nbsp; &nbsp;associated&nbsp;&nbsp; &nbsp;with&nbsp;&nbsp; &nbsp;LAT&nbsp;&nbsp; &nbsp;were&nbsp;&nbsp; &nbsp;assessed&nbsp;&nbsp; &nbsp;and&nbsp;&nbsp; &nbsp;introduced&nbsp;&nbsp; &nbsp;in&nbsp;&nbsp; &nbsp;<br> predictive models to develop both a clinical and an echocardiographic prediction&nbsp;<br> score&nbsp;&nbsp; &nbsp;for&nbsp;&nbsp; &nbsp;the&nbsp;&nbsp; &nbsp;presence&nbsp;&nbsp; &nbsp;of&nbsp;&nbsp; &nbsp;LAT.<br> Results: In&nbsp;&nbsp; &nbsp;total,&nbsp;&nbsp; &nbsp;125&nbsp;&nbsp; &nbsp;patients&nbsp;&nbsp; &nbsp;[median&nbsp;&nbsp; &nbsp;71&nbsp;&nbsp; &nbsp;(range&nbsp;&nbsp; &nbsp;49-88)&nbsp;&nbsp; &nbsp;years,&nbsp;&nbsp; &nbsp;60.0%&nbsp;&nbsp; &nbsp;males]&nbsp;&nbsp; &nbsp;were&nbsp;&nbsp; &nbsp;<br> enrolled.&nbsp;&nbsp; &nbsp;Transesophageal&nbsp;&nbsp; &nbsp;echocardiography&nbsp;&nbsp; &nbsp;showed&nbsp;&nbsp; &nbsp;LAT&nbsp;&nbsp; &nbsp;in&nbsp;&nbsp; &nbsp;35&nbsp;&nbsp; &nbsp;patients&nbsp;&nbsp; &nbsp;(28%).&nbsp;&nbsp; &nbsp;The&nbsp;&nbsp; &nbsp;<br> clinical&nbsp;&nbsp; &nbsp;variables&nbsp;&nbsp; &nbsp;significantly&nbsp;&nbsp; &nbsp;associated&nbsp;&nbsp; &nbsp;with&nbsp;&nbsp; &nbsp;LAT&nbsp;&nbsp; &nbsp;were&nbsp;&nbsp; &nbsp;previous&nbsp;&nbsp; &nbsp;stroke&nbsp;&nbsp; &nbsp;(OR&nbsp;&nbsp; &nbsp;=&nbsp;&nbsp; &nbsp;4.17),&nbsp;&nbsp; &nbsp;<br> higher&nbsp;&nbsp; &nbsp;CHA2DS2-VASc&nbsp;&nbsp; &nbsp;score&nbsp;&nbsp; &nbsp;(OR&nbsp;&nbsp; &nbsp;=&nbsp;&nbsp; &nbsp;1.93),&nbsp;&nbsp; &nbsp;lower&nbsp;&nbsp; &nbsp;estimated&nbsp;&nbsp; &nbsp;glomerular&nbsp;&nbsp; &nbsp;filtration&nbsp;&nbsp; &nbsp;rate&nbsp;&nbsp; &nbsp;<br> (OR&nbsp;&nbsp; &nbsp;=&nbsp;&nbsp; &nbsp;0.80),&nbsp;&nbsp; &nbsp;and&nbsp;&nbsp; &nbsp;higher&nbsp;&nbsp; &nbsp;brain&nbsp;&nbsp; &nbsp;natriuretic&nbsp;&nbsp; &nbsp;peptide&nbsp;&nbsp; &nbsp;levels&nbsp;&nbsp; &nbsp;(OR&nbsp;&nbsp; &nbsp;=&nbsp;&nbsp; &nbsp;1.44).&nbsp;&nbsp; &nbsp;Among&nbsp;&nbsp; &nbsp;echocar-<br> diographic&nbsp;&nbsp; &nbsp;parameters,&nbsp;&nbsp; &nbsp;E/e&prime;&nbsp;&nbsp; &nbsp;ratio&nbsp;&nbsp; &nbsp;was&nbsp;&nbsp; &nbsp;directly&nbsp;&nbsp; &nbsp;associated&nbsp;&nbsp; &nbsp;with&nbsp;&nbsp; &nbsp;LAT&nbsp;&nbsp; &nbsp;(OR&nbsp;&nbsp; &nbsp;=&nbsp;&nbsp; &nbsp;2.25),&nbsp;&nbsp; &nbsp;while&nbsp;&nbsp; &nbsp;<br> an&nbsp;&nbsp; &nbsp;inverse&nbsp;&nbsp; &nbsp;correlation&nbsp;&nbsp; &nbsp;was&nbsp;&nbsp; &nbsp;detected&nbsp;&nbsp; &nbsp;with&nbsp;&nbsp; &nbsp;left&nbsp;&nbsp; &nbsp;ventricular&nbsp;&nbsp; &nbsp;ejection&nbsp;&nbsp; &nbsp;fraction&nbsp;&nbsp; &nbsp;(OR&nbsp;&nbsp; &nbsp;=&nbsp;&nbsp; &nbsp;0.43)&nbsp;&nbsp; &nbsp;<br> and&nbsp;&nbsp; &nbsp;total&nbsp;&nbsp; &nbsp;global&nbsp;&nbsp; &nbsp;left&nbsp;&nbsp; &nbsp;atrial&nbsp;&nbsp; &nbsp;strain&nbsp;&nbsp; &nbsp;(OR&nbsp;&nbsp; &nbsp;=&nbsp;&nbsp; &nbsp;0.59).&nbsp;&nbsp; &nbsp;Two&nbsp;&nbsp; &nbsp;prediction&nbsp;&nbsp; &nbsp;scores&nbsp;&nbsp; &nbsp;(clinical&nbsp;&nbsp; &nbsp;and&nbsp;&nbsp; &nbsp;echo-<br> cardiographic)&nbsp;&nbsp; &nbsp;were&nbsp;&nbsp; &nbsp;developed.&nbsp;&nbsp; &nbsp;The&nbsp;&nbsp; &nbsp;positive&nbsp;&nbsp; &nbsp;predictive&nbsp;&nbsp; &nbsp;values&nbsp;&nbsp; &nbsp;of&nbsp;&nbsp; &nbsp;the&nbsp;&nbsp; &nbsp;clinical&nbsp;&nbsp; &nbsp;and&nbsp;&nbsp; &nbsp;the&nbsp;&nbsp; &nbsp;<br> echocardiographic&nbsp;&nbsp; &nbsp;score&nbsp;&nbsp; &nbsp;were&nbsp;&nbsp; &nbsp;80%&nbsp;&nbsp; &nbsp;and&nbsp;&nbsp; &nbsp;100%,&nbsp;&nbsp; &nbsp;respectively,&nbsp;&nbsp; &nbsp;while&nbsp;&nbsp; &nbsp;the&nbsp;&nbsp; &nbsp;negative&nbsp;&nbsp; &nbsp;pre-<br> dictive&nbsp;&nbsp; &nbsp;values&nbsp;&nbsp; &nbsp;were&nbsp;&nbsp; &nbsp;98%&nbsp;&nbsp; &nbsp;and&nbsp;&nbsp; &nbsp;94%,&nbsp;&nbsp; &nbsp;respectively.&nbsp;&nbsp; &nbsp;Combined&nbsp;&nbsp; &nbsp;use&nbsp;&nbsp; &nbsp;of&nbsp;&nbsp; &nbsp;the&nbsp;&nbsp; &nbsp;scores&nbsp;&nbsp; &nbsp;reached&nbsp;&nbsp; &nbsp;<br> a&nbsp;&nbsp; &nbsp;positive&nbsp;&nbsp; &nbsp;and&nbsp;&nbsp; &nbsp;negative&nbsp;&nbsp; &nbsp;predictive&nbsp;&nbsp; &nbsp;value&nbsp;&nbsp; &nbsp;of&nbsp;&nbsp; &nbsp;100%.<br> Conclusions: When providing concordant information the two scores are able to cor-<br> rectly&nbsp;&nbsp; &nbsp;identify&nbsp;&nbsp; &nbsp;patients&nbsp;&nbsp; &nbsp;with&nbsp;&nbsp; &nbsp;or&nbsp;&nbsp; &nbsp;without&nbsp;&nbsp; &nbsp;LAT.&nbsp;&nbsp; &nbsp;An&nbsp;&nbsp; &nbsp;external&nbsp;&nbsp; &nbsp;validation&nbsp;&nbsp; &nbsp;is&nbsp;&nbsp; &nbsp;necessary&nbsp;&nbsp; &nbsp;to&nbsp;&nbsp; &nbsp;<br> demonstrate their usefulness in the clinical practice.</p>