Wednesday, September 23, 2015

Extracranial systemic embolism in patients with non valvular atrial fibrillation

It occurs much less frequently than stroke. Here are findings from several trials:

Methods and Results—All suspected SEE reported among 37,973 participants of four large contemporary randomized clinical trials of anticoagulation in AF were independently re-adjudicated for clinical and objective evidence of sudden loss of perfusion of a limb or organ. Over 91,746 patient-years of follow-up, 221 SEE occurred in 219 subjects. The SEE incidence was 0.24/100 and stroke incidence was 1.92/100 patient-years. Compared to patients with stroke, those with SEE were more often female (56% vs. 47%; p=0.01), had comparable mean age (73.1±8.5 vs. 73.5±8.8 years, p=0.57) and mean CHADS2 scores (2.4±1.3 vs 2.5±1.2; p=0.33). SEE more frequently involved the lower extremity (58%), than visceral-mesenteric (31%) or upper extremity (10%). SEE-related care involved clinic assessment alone in 5%, 30% were hospitalized without procedures, 60% underwent endovascular or surgical intervention, and 5% underwent amputation. Within 30 days, 54% of patients recovered fully, 20% survived with deficits and 24% died. 30-day mortality was greater after visceral-mesenteric than lower or upper extremity SEE (55%, 17% and 9%, respectively, p= less than 0.0001). The relative risk of death throughout follow-up was 4.33 (95% CI 3.29-5.70) after SEE vs. 6.79 (95% CI 6.22-7.41) after stroke, compared to patients without either event.

Conclusions—SEE constituted 11.5% of clinically-recognized thromboembolic events in patients with AF and was associated with high morbidity and mortality. SEE mortality was comparable to that of ischemic stroke and varied by anatomic site.

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