Role of the CHADS2 Score in the Evaluation of Thromboembolic Risk in Patients With Atrial Fibrillation Undergoing Transesophageal Echocardiography Before Pulmonary Vein Isolation

Sarinya Puwanant, Brandon C. Varr, Kevin Shrestha, Sarah Hussain, W. H.Wilson Tang, Ruvin S. Gabriel, Oussama M. Wazni, Mandeep Bhargava, Walid I. Saliba, James D. Thomas, Bruce D. Lindsay, Allan L. Klein

Research output: Contribution to journalArticle

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Abstract

Objectives: The goals of this study were to determine: 1) if low-risk patients assessed by a CHADS2 score, a clinical scoring system quantifying a risk of stroke in patients with atrial fibrillation (AF), require a routine screening transesophageal echocardiogram (TEE) before pulmonary vein isolation (PVI); and 2) the relationship of a CHADS2 score with left atrial (LA)/left atrial appendage (LAA) spontaneous echo contrast, sludge, and thrombus. Background: There is no clear consensus of whether a screening TEE before catheter ablation of AF should be performed in every patient. Methods: Initial TEEs for pre-PVI of 1,058 AF patients (age 57 ± 11 years, 80% men) were reviewed and compared with a CHADS2 score. Results: CHADS2 scores of 0, 1, 2, 3, 4, 5, and 6 were present in 47%, 33%, 14%, 5%, 1%, 0.3%, and 0% of patients, respectively. The prevalence of LA/LAA thrombus, sludge, and spontaneous echo contrast were present in 0.6%, 1.5%, and 35%. The prevalence of LA/LAA thrombus/sludge increased with ascending CHADS2 score (scores 0 [0%], 1 [2%], 2 [5%], 3 [9%], and 4 to 6 [11%], p < 0.01). No patient with a CHADS2 score of 0 had LA/LAA sludge/thrombus. In a multivariate model, history of congestive heart failure and left ventricular ejection fraction <35% were significantly associated with sludge/thrombus. Conclusions: The prevalence of LA/LAA sludge/thrombus in patients with AF undergoing a pre-PVI screening TEE is very low (<2%) and increases significantly with higher CHADS2 scores. This suggests that a screening TEE before PVI should be performed in patients with a CHADS2 score of ≥1, and in patients with a CHADS2 score of 0 when the AF is persistent and therapeutic anticoagulation has not been maintained for 4 weeks before the procedure.

Original languageEnglish (US)
Pages (from-to)2032-2039
Number of pages8
JournalJournal of the American College of Cardiology
Volume54
Issue number22
DOIs
StatePublished - Nov 24 2009

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Pulmonary Veins
Transesophageal Echocardiography
Atrial Fibrillation
Atrial Appendage
Sewage
Thrombosis
Catheter Ablation
Stroke Volume
Heart Failure
Stroke

All Science Journal Classification (ASJC) codes

  • Cardiology and Cardiovascular Medicine

Cite this

Puwanant, Sarinya ; Varr, Brandon C. ; Shrestha, Kevin ; Hussain, Sarah ; Tang, W. H.Wilson ; Gabriel, Ruvin S. ; Wazni, Oussama M. ; Bhargava, Mandeep ; Saliba, Walid I. ; Thomas, James D. ; Lindsay, Bruce D. ; Klein, Allan L. / Role of the CHADS2 Score in the Evaluation of Thromboembolic Risk in Patients With Atrial Fibrillation Undergoing Transesophageal Echocardiography Before Pulmonary Vein Isolation. In: Journal of the American College of Cardiology. 2009 ; Vol. 54, No. 22. pp. 2032-2039.
@article{9de67b9e80d549a0b0c3ce1fe1c06d29,
title = "Role of the CHADS2 Score in the Evaluation of Thromboembolic Risk in Patients With Atrial Fibrillation Undergoing Transesophageal Echocardiography Before Pulmonary Vein Isolation",
abstract = "Objectives: The goals of this study were to determine: 1) if low-risk patients assessed by a CHADS2 score, a clinical scoring system quantifying a risk of stroke in patients with atrial fibrillation (AF), require a routine screening transesophageal echocardiogram (TEE) before pulmonary vein isolation (PVI); and 2) the relationship of a CHADS2 score with left atrial (LA)/left atrial appendage (LAA) spontaneous echo contrast, sludge, and thrombus. Background: There is no clear consensus of whether a screening TEE before catheter ablation of AF should be performed in every patient. Methods: Initial TEEs for pre-PVI of 1,058 AF patients (age 57 ± 11 years, 80{\%} men) were reviewed and compared with a CHADS2 score. Results: CHADS2 scores of 0, 1, 2, 3, 4, 5, and 6 were present in 47{\%}, 33{\%}, 14{\%}, 5{\%}, 1{\%}, 0.3{\%}, and 0{\%} of patients, respectively. The prevalence of LA/LAA thrombus, sludge, and spontaneous echo contrast were present in 0.6{\%}, 1.5{\%}, and 35{\%}. The prevalence of LA/LAA thrombus/sludge increased with ascending CHADS2 score (scores 0 [0{\%}], 1 [2{\%}], 2 [5{\%}], 3 [9{\%}], and 4 to 6 [11{\%}], p < 0.01). No patient with a CHADS2 score of 0 had LA/LAA sludge/thrombus. In a multivariate model, history of congestive heart failure and left ventricular ejection fraction <35{\%} were significantly associated with sludge/thrombus. Conclusions: The prevalence of LA/LAA sludge/thrombus in patients with AF undergoing a pre-PVI screening TEE is very low (<2{\%}) and increases significantly with higher CHADS2 scores. This suggests that a screening TEE before PVI should be performed in patients with a CHADS2 score of ≥1, and in patients with a CHADS2 score of 0 when the AF is persistent and therapeutic anticoagulation has not been maintained for 4 weeks before the procedure.",
author = "Sarinya Puwanant and Varr, {Brandon C.} and Kevin Shrestha and Sarah Hussain and Tang, {W. H.Wilson} and Gabriel, {Ruvin S.} and Wazni, {Oussama M.} and Mandeep Bhargava and Saliba, {Walid I.} and Thomas, {James D.} and Lindsay, {Bruce D.} and Klein, {Allan L.}",
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doi = "10.1016/j.jacc.2009.07.037",
language = "English (US)",
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pages = "2032--2039",
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}

Role of the CHADS2 Score in the Evaluation of Thromboembolic Risk in Patients With Atrial Fibrillation Undergoing Transesophageal Echocardiography Before Pulmonary Vein Isolation. / Puwanant, Sarinya; Varr, Brandon C.; Shrestha, Kevin; Hussain, Sarah; Tang, W. H.Wilson; Gabriel, Ruvin S.; Wazni, Oussama M.; Bhargava, Mandeep; Saliba, Walid I.; Thomas, James D.; Lindsay, Bruce D.; Klein, Allan L.

In: Journal of the American College of Cardiology, Vol. 54, No. 22, 24.11.2009, p. 2032-2039.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Role of the CHADS2 Score in the Evaluation of Thromboembolic Risk in Patients With Atrial Fibrillation Undergoing Transesophageal Echocardiography Before Pulmonary Vein Isolation

AU - Puwanant, Sarinya

AU - Varr, Brandon C.

AU - Shrestha, Kevin

AU - Hussain, Sarah

AU - Tang, W. H.Wilson

AU - Gabriel, Ruvin S.

AU - Wazni, Oussama M.

AU - Bhargava, Mandeep

AU - Saliba, Walid I.

AU - Thomas, James D.

AU - Lindsay, Bruce D.

AU - Klein, Allan L.

PY - 2009/11/24

Y1 - 2009/11/24

N2 - Objectives: The goals of this study were to determine: 1) if low-risk patients assessed by a CHADS2 score, a clinical scoring system quantifying a risk of stroke in patients with atrial fibrillation (AF), require a routine screening transesophageal echocardiogram (TEE) before pulmonary vein isolation (PVI); and 2) the relationship of a CHADS2 score with left atrial (LA)/left atrial appendage (LAA) spontaneous echo contrast, sludge, and thrombus. Background: There is no clear consensus of whether a screening TEE before catheter ablation of AF should be performed in every patient. Methods: Initial TEEs for pre-PVI of 1,058 AF patients (age 57 ± 11 years, 80% men) were reviewed and compared with a CHADS2 score. Results: CHADS2 scores of 0, 1, 2, 3, 4, 5, and 6 were present in 47%, 33%, 14%, 5%, 1%, 0.3%, and 0% of patients, respectively. The prevalence of LA/LAA thrombus, sludge, and spontaneous echo contrast were present in 0.6%, 1.5%, and 35%. The prevalence of LA/LAA thrombus/sludge increased with ascending CHADS2 score (scores 0 [0%], 1 [2%], 2 [5%], 3 [9%], and 4 to 6 [11%], p < 0.01). No patient with a CHADS2 score of 0 had LA/LAA sludge/thrombus. In a multivariate model, history of congestive heart failure and left ventricular ejection fraction <35% were significantly associated with sludge/thrombus. Conclusions: The prevalence of LA/LAA sludge/thrombus in patients with AF undergoing a pre-PVI screening TEE is very low (<2%) and increases significantly with higher CHADS2 scores. This suggests that a screening TEE before PVI should be performed in patients with a CHADS2 score of ≥1, and in patients with a CHADS2 score of 0 when the AF is persistent and therapeutic anticoagulation has not been maintained for 4 weeks before the procedure.

AB - Objectives: The goals of this study were to determine: 1) if low-risk patients assessed by a CHADS2 score, a clinical scoring system quantifying a risk of stroke in patients with atrial fibrillation (AF), require a routine screening transesophageal echocardiogram (TEE) before pulmonary vein isolation (PVI); and 2) the relationship of a CHADS2 score with left atrial (LA)/left atrial appendage (LAA) spontaneous echo contrast, sludge, and thrombus. Background: There is no clear consensus of whether a screening TEE before catheter ablation of AF should be performed in every patient. Methods: Initial TEEs for pre-PVI of 1,058 AF patients (age 57 ± 11 years, 80% men) were reviewed and compared with a CHADS2 score. Results: CHADS2 scores of 0, 1, 2, 3, 4, 5, and 6 were present in 47%, 33%, 14%, 5%, 1%, 0.3%, and 0% of patients, respectively. The prevalence of LA/LAA thrombus, sludge, and spontaneous echo contrast were present in 0.6%, 1.5%, and 35%. The prevalence of LA/LAA thrombus/sludge increased with ascending CHADS2 score (scores 0 [0%], 1 [2%], 2 [5%], 3 [9%], and 4 to 6 [11%], p < 0.01). No patient with a CHADS2 score of 0 had LA/LAA sludge/thrombus. In a multivariate model, history of congestive heart failure and left ventricular ejection fraction <35% were significantly associated with sludge/thrombus. Conclusions: The prevalence of LA/LAA sludge/thrombus in patients with AF undergoing a pre-PVI screening TEE is very low (<2%) and increases significantly with higher CHADS2 scores. This suggests that a screening TEE before PVI should be performed in patients with a CHADS2 score of ≥1, and in patients with a CHADS2 score of 0 when the AF is persistent and therapeutic anticoagulation has not been maintained for 4 weeks before the procedure.

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