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A Prospective Study of 1066 Patients From 3 Clinical Trials

Atrial Fibrillation Investigators: Atrial Fibrillation, Aspirin, Anticoagulation Study; European Atrial Fibrillation Study; Stroke Prevention in Atrial Fibrillation Study; Boston Area Anticoagulation Trial for Atrial Fibrillation Study; Canadian Atrial Fibrillation Study; Veterans Affairs Prevention in Atrial Fibrillation Study

Arch Intern Med. 1998;158:1316-1320.

Background  Clinical features that consistently predict ischemic stroke in patients with nonvalvular atrial fibrillation have been identified, while echocardiographic risk factors are less well defined.

Objective  To determine whether the results of transthoracic echocardiography add independent information to the clinical risk factors for stroke in patients with atrial fibrillation.

Methods  Transthoracic echocardiographic findings and clinical features from 1066 patients with atrial fibrillation assigned to placebo or control in 3 randomized trials (Boston Area Anticoagulation Trial for Atrial Fibrillation, Stroke Prevention in Atrial Fibrillation I Study, and Veterans Affairs Prevention in Atrial Fibrillation Study) were correlated with subsequent ischemic stroke by multivariate analysis.

Results  The mean±SD age of patients was 67±10 years, 78% were men, 55% had a history of hypertension, 19% had a history of diabetes, 7% had a previous transient ischemic attack or stroke, and 27% had a history of heart failure. During a mean follow-up of 1.6 years, 78 ischemic strokes occurred (annual rate, 4.7%). Moderate to severe left ventricular systolic dysfunction shown via 2-dimensional echocardiography was a strong independent predictor of stroke (relative risk, 2.5; P<.001) in the 1010 patients in whom echocardiographic values for left ventricular function were available. Left atrial diameter by M-mode echocardiography did not predict stroke (relative risk, 1.02/mm; P=.10). Of 163 patients categorized as low risk based on clinical features (annual stroke rate, 0.8%; 95% confidence interval, 0.2%-3.0%), 10 had moderate to severe left ventricular dysfunction shown via 2-dimensional echocardiography and a 9.3% per year risk of stroke (95% confidence interval, 1.3%-66%). Conversely, 728 of the 847 patients at high risk for stroke based on clinical criteria had normal or mildly abnormal left ventricular function; their stroke rate was 4.4% (95% confidence interval, 3.4%-5.8%).

Conclusions  Left ventricular systolic dysfunction shown via 2-dimensional transthoracic echocardiography independently predicts risk of stroke in patients with atrial fibrillation. Echocardiography may prove most useful in a small group of patients who have a low risk of stroke according to clinical factors.

This study was supported by grant R0124224 from the Division of Stroke and Trauma, National Institute of Neurological Disorders and Stroke, Bethesda, Md, and by a grant from DuPont-Merck Pharmaceuticals, Wilmington, Del.

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