Need For Long-term Anticoagulation Research Articles

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Apical Hypertrophic Cardiomyopathy.

To the Editor We have read with interest the excellent review on hypertrophic cardiomyopathy (HCM)1 and wish to comment on the apical variant of the disease listed in Table 4 but not discussed in the text. This variant can be found in 15% to 25% of Chinese and Japanese cohorts with HCM but only in 3% of American cohorts.2 The typical electrocardiography (ECG) shows the loss of septal Q waves, high QRS voltage, and repolarization abnormalities with deep T-wave inversion, especially in the leads closest to the apex—V4–V6.2 Because hypertrophy is confined to the apex, dynamic left ventricular outflow tract obstruction and systolic anterior motion of the anterior mitral valve leaflet are absent. The apical pulse may be sustained on palpation, and an S4 heart sound may be heard.2 There may not be a systolic murmur. It is reasonable to expect some degree of diastolic dysfunction and the possibility of relative apical ischemia as a result of the unbalanced wall thickness-to-vascular supply ratio.3 HCM apical variant may not have a totally benign prognosis with atrial fibrillation and myocardial infarction occurring in up to one-third of patients during long-term follow-up in the Western population.3,4 In addition, in patients with atrial fibrillation, HCM (including the apical variant) may increase the risks of systemic thromboembolism and the need for long-term anticoagulation.5,6 However, there are currently no data to suggest that the perioperative risks are increased in afflicted patients without a history of syncope, chest pain, dyspnea, or heart failure. Nonetheless, in a young asymptomatic patient, the bizarre ECG pattern first seen when intraoperative ECG electrodes are placed can be alarming and may even lead to the postponement of surgery or initiation of coronary vasodilator treatment. Alternatively, a preoperative ECG may lead one to suspect HCM. However, plain echocardiography may still miss apical HCM if the apex is not adequately examined.3 A microbubble contrast-enhanced echocardiography or cardiac magnetic resonance imaging, or both, may be required to differentially diagnose apical HCM, coronary artery disease, myocardial tumor, ventricular aneurysm, ventricular noncompaction, or endomyocardial fibrosis.3 Anthony M. H. Ho, MD, FRCPC, FCCP Department of Anesthesiology and Perioperative Medicine Queen’s University and Kingston General Hospital Kingston, Ontario, Canada [email protected] Po T. Chui, MBBS, FANZCA Alex P. W. Lee, MBChB, MRCP Song Wan, PhD, MD, FRCS Departments of Anaesthesia and Intensive Care, Medicine & Therapeutics, and Surgery The Chinese University of Hong Kong and Prince of Wales Hospital Hong Kong SAR, People’s Republic of China

A meta-analysis of left atrial appendage closure for stroke prevention in atrial fibrillation-adding to the debate but elements remain unresolved.

Managing the trade off between stroke risk and bleeding risk is a key challenge in patients with atrial fibrillation (AF). In 90% of patients with non-valvular AF and intracardiac thrombus, the left atrial appendage (LAA) is thought to be the location (1). The advent of devices to occlude the LAA therefore raised the possibility that stroke risk could be eliminated in this group of patients without the need for long term anticoagulation. However, since the first reports of percutaneous LAA closure with the PLAATO device were published in 2002, progress has been somewhat limited (2). Despite the initial optimism, concerns surrounding safety and efficacy have restricted the number of devices receiving FDA approval (3) and limited commissioning of this treatment in the United Kingdom (4). Guidelines for the management AF to date have varied their advice on this technology with European Guidelines giving LAA closure devices a “IIb” recommendation (usefulness/efficacy is less well established by evidence/opinion) and this only in patients who have a contraindication to warfarin (5). North American Guidelines do not currently recommend LAA closure at all (6). In some ways the caution in recommending this technology is understandable given the paucity of data to support their use.

Left Atrial Appendage Closure for Atrial Fibrillation Is Safe and Effective After Intracranial or Intraocular Hemorrhage

BackgroundAtrial fibrillation (AF) affects 1%-2% of the general population and 13% of individuals older than 80 years of age. Anticoagulation has been the mainstay therapy to reduce stroke risk. Patients with previous intracranial hemorrhage (ICH) or intraocular hemorrhage (IOH) are at increased risk of recurrence if anticoagulation is continued or initiated. Left atrial appendage (LAA) closure may obviate the need for long-term anticoagulation in these patients. MethodsWe report our consecutive series of patients with nonvalvular AF with previous ICH or IOH who underwent LAA closure with the AMPLATZER Cardiac Plug (ACP; St Jude Medical, St Paul, MN), AMPLATZER Amulet, or WATCHMAN (Boston Scientific, Natick, MA) device. Demographics, clinical status, procedural outcomes, and complications were collected at baseline, during the procedure, at 3 months, at 1 year, and annually thereafter. ResultsTwenty-six patients with previous ICH (n = 24) or IOH (n = 2) underwent LAA closure (9 with the ACP, 3 with the Amulet, and 7 with the WATCHMAN). The mean age was 76 ± 7 years, and 61.5% were men with a mean CHADS2 (Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack) score of 3.2 ± 1.4 and CHA2DS2-VASc (Congestive Heart Failure, Hypertension, Age [≥ 75 years], Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age [65-74 years], Sex [Female] score) of 4.9 ± 1.7. No procedure-related complications occurred. Mean follow-up was 11.9 ± 13.3 months. One patient died at 13 months (this death was not related to the procedure), and 1 patient had a transient ischemic attack at 20.6 months after the procedure. No ischemic stroke, haemorrhagic stroke, or bleeding problems occurred during follow-up. ConclusionsIn our consecutive series, LAA closure was found to be safe and effective in patients with AF and a history of ICH or IOH.

Percutaneous management of late leak after lariat transcatheter ligation of the left atrial appendage in patients with atrial fibrillation at high risk for stroke

Left atrial appendage (LAA) occlusion or ligation is a novel approach to stroke prevention in atrial fibrillation that may obviate the need for long-term anticoagulation. The Lariat device has received Food and Drug Administration 510K clearance for the approximation of soft tissue and has been applied to transcatheter LAA ligation using a combined trans-pericardial and transseptal approach. The occurrence of late leak after transcatheter LAA ligation and its percutaneous management has not been previously reported. Herein, we report three cases of late leak with reconstitution of the LAA after initially successful Lariat closure, and present a simple percutaneous technique for leak closure.

Compressive Symptoms Due to Thrombosed or Hypertrophic Collateral Circulation in Infrarenal Inferior Vena Cava Agenesis

Agenesis of the infrarenal segment of inferior vena cava is an uncommon and often asymptomatic congenital abnormality with an approximate incidence of 0.005-1% in the general population. Presentation of this condition as deep venous thrombosis associated with symptoms secondary to thrombosis or hypertrophy of collateral vessels is a rare clinical form. Two cases of this rare form are described, and an analysis of the related literature is presented. The first case was that of a 35-year-old man with symptoms of acute obstructive pyelonephritis with no apparent cause and swelling of the lower limb. The second case involved a 30-year-old man with lower limb swelling associated with paresthesia and motor deficit. Both patients were found to have infrarenal inferior vena cava agenesis associated with iliofemoral deep venous thrombosis and compression of anatomic structures by collateral vessels (ureteral compression due to thrombosis of an ectatic gonadal vein and L5 nerve root compression due to a hypertrophic epidural venous plexus). Patients were conservatively managed with anticoagulation therapy, with a favorable outcome and no recurrence in either case. In a young patient with iliac deep venous thrombosis of uncertain etiology, and particularly in those with atypical associated symptoms (mainly abdominal or neurologic), it is important to investigate congenital vena cava anomalies and carry out diagnostic imaging studies. Anticoagulation therapy is currently considered the best treatment option for this condition, but it should be individualized. The need for long-term anticoagulation should also be assessed in each case.

Budd–Chiari syndrome in children and outcome after liver transplant

BCS is a rare form of portal hypertension in children. The authors describe two cases of BCS with differing presentations. Case 1: Previously healthy four-yr-old girl. BCS was diagnosed during the course of an episode of acute gastroenteritis with dehydration. Despite conservative therapy for two months, the condition was progressive resulting in liver failure leading ultimately to LT. Molecular studies showed that she was heterozygous for the Factor (F) V Leiden. At follow-up, six yr post-LT (two yr without anticoagulation therapy), no thromboembolic/bleeding events were apparent. Case 2: Three-yr-old boy with IgA deficiency and liver disease. Following a febrile episode, he developed fulminant liver failure requiring urgent LT from a living donor (father). Molecular studies disclosed MTHFR C677T homozygosity and FV Leiden heterozygosity. The father was homozygous for the MTHFR mutation. Three months post-LT, persistent graft dysfunction was associated with stenosis of the IVC, which improved upon stent placement. He received dipyridamole and aspirin for five yr, after which time dipyridamole was discontinued. Evidence is sparse on the follow-up of BCS cases with liver transplant. The authors discuss their findings, particularly the need for long-term anticoagulation.

Abstract 9678: Long Term Results of Aortic Valve and Root Replacement in 1045 Patients Over Thirty-Three Years. A Single-Centre Experience

Introduction. Aortic root replacement using composite graft represents the treatment of choice for a large variety of aortic root diseases. The aim of the current study is to evaluate the long-term results of this procedure. Methods. Between 1978 and 2010, 1045 patients aged 58.7±13.6 years (834 males) underwent aortic root composite graft replacement: 95 (9.1%) underwent Bentall operation, 926 (88.6%) were operated following the “button technique”, whereas 24 (2.3%) underwent Cabrol technique. Six-hundred thirty five patients (62.3%) had annuloaortic ectasia and 162 (15.5%) aortic dissection. Results. Overall in-hospital mortality was 5.3% (55/1045). Independent risk factors for in-hospital mortality at logistic regression analysis were age (p=0.051,OR=3.2), preoperative NYHA class III-IV (p=0.015,OR=5.9), aortic dissection (p=0.059,OR=3.6) and Cabrol technique (p=0.065,OR=2.2). Overall actuarial survival at 5, 10, and 20 years was 84.1%±1.3%, 65.5%±2.6%, and 40.7%±4.6%, respectively. Multivariate analysis revealed preoperative EF&lt;50% (p=0.057, OR=3.1), postoperative neurologic complications (p=0.013, OR=6.1) and postoperative pulmonary complications (p=0.046, OR=3.9) to be significant predictors of late death. Freedom from thromboembolism, freedom from bleeding complications, and freedom from endocarditis was 93.7%±2.6%, 90.3%±3.1%, and 98.4%±1% at 20 years, respectively. Freedom from aortic reoperation was 91.8%±2.1% at 20 years, and was significantly lower in patients with aortic dissection. Conclusions. Aortic root replacement for aortic root aneurysms can be performed with low morbidity and mortality and with satisfactory long-term results. Few late serious complications were related to the need for long-term anticoagulation or a prosthetic valve. Reoperation on the proximal or in the distal aorta was most commonly performed in patients with aortic dissection.

What’s new in the other journals?

What’s new in the other journals?

Managing catheter ablation for atrial fibrillation: the role of echocardiography

Atrial fibrillation (AF) is a common arrhythmia associated with the serious clinical consequences of systemic thrombo-embolism and heart failure. Catheter ablation for AF is an evolving treatment option for patients with drug-refractory paroxysmal and persistent AF. The ablation procedure relies on precise knowledge of the left atrium, left atrial appendage, and pulmonary venous anatomy and function. Echocardiography is an integral component of multiple imaging modalities which contribute to its success. Both transoesophageal echocardiography and transthoracic echocardiography provide essential anatomical and functional information to guide all aspects of management. This article reviews the role of echocardigraphy in AF ablation, from appropriate patient selection and pre-procedural screening, to evaluating complications and determining the need for long-term anticoagulation.

Choice of Prosthetic Heart Valve in Today’s Practice

In this update, current guidelines addressing prosthesis selection published by the American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) are discussed, along with additional data that affect choices in valve prostheses. The case of a 50-year-old man undergoing aortic valve replacement is used to address anticipated operative mortality, risk of reoperation, and valve-related morbidity and mortality. The apparent advantages associated with the use of a bioprosthesis even in a relatively young patient help to explain current clinical trends toward the increasing use of tissue valves. We also provide a simplified algorithm that may be used to facilitate the choice of valve procedure in patients with heart valve disease. The outcomes after surgery for valvular heart disease in terms of survival, functional status, and quality of life are determined primarily by patient-related factors such as age, ventricular function, and other comorbidities.1 However, outcomes also are influenced by surgical factors; the best clinical outcomes often are associated with valve repair, although mitral repair is not always possible and aortic valve repair in adults remains the exception rather than the rule. For patients who require valve replacement, the valve prosthesis can significantly influence outcome. The ideal prosthetic valve that combines excellent hemodynamic performance and long-term durability without increased thromboembolic risk or the need for long-term anticoagulation does not exist. Hence, patients and their physicians need to choose between a mechanical and a tissue (bioprosthetic) valve. In general, the advantageous durability of mechanical valves is offset by the risk of thromboembolism and the need for long-term anticoagulation and its associated risk of bleeding. In contrast, bioprosthetic valves do not require long-term anticoagulation yet carry the risk of structural failure and reoperation.2,3 Two historic randomized clinical trials compared outcomes after valve replacement with a first-generation porcine heterograft …

Aortic Valve Preservation in Marfan Syndrome. Initial Experience

Preservation of the aortic valve using the technique described by David has been shown to be as effective as the Bentall-De Bono procedure. It avoids both the need for long-term anticoagulation and the complications associated with mechanical prostheses. We report our initial experience using this technique in patients with Marfan syndrome. Between April 2004 and April 2006, we used the David reimplantation technique in 40 patients with an aortic root aneurysm. Eighteen patients had Marfan syndrome. Their median age was 29 years (13-55 years). Echocardiography showed that the median diameter of the aortic sinus was 53 mm (46-59 mm). In 17 patients, aortic valve preservation was possible. No patient died during hospitalization and there were no significant complications. On echocardiography at discharge, no patient had greater than grade-II aortic regurgitation. During a median follow-up period of 8 months (1-24 months), one patient died due to rupture of an abdominal aneurysm. The others are all in New York Heart Association class I. Preservation of the aortic valve by means of valve reimplantation produced excellent results. It avoided both the thromboembolic and hemorrhagic complications associated with prostheses and the need for long-term anticoagulation. If reimplanted valves continue to function adequately over the long term, this technique should become the treatment of choice for aneurysms of the ascending aorta in patients with Marfan syndrome.

Retrievable and Permanent Inferior Vena Cava Filters: Selected Considerations

The use of inferior vena cava (IVC) filters is increasing rapidly, and the recent availability of retrievable IVC filters is certain to accelerate this process. Unfortunately, because the risks and benefits of these devices have not been adequately studied, several important issues remain. Limitations of the quality of the data in the available literature make it virtually impossible to accurately quantify the specific rates of complications with various devices. Although many clinicians believe that the use of an IVC filter obviates anticoagulation, new data support the need for long-term anticoagulation in such patients. The recent introduction of retrievable IVC filters may eliminate the need for long-term anticoagulation if the filter can be removed, but further data are needed to ascertain the place of these devices in modern therapy. The increasing use of these devices increases the need for clinicians to be aware of the potential limitations and risks of IVC filters.

The Importance of Thrombophilia in the Treatment of Paget-Schroetter Syndrome

Venous thoracic outlet syndrome (V-TOS) and associated subclavian vein thrombosis (SVT) result in significant patient morbidity and can be difficult to manage. Previous studies have suggested that both mechanical compressive factors and pathological alterations in patient coagulation may contribute to the development of SVT; however, no study has specifically evaluated the role of thrombophilia in the treatment of V-TOS and the need for long-term anticoagulation as an adjunct to surgical decompression. This retrospective study describes the clinical courses of 18 patients treated for V-TOS with and without acute SVT. In this review, 67% of patients with SVT are found to have relatively common coagulation disorders and 90% of postoperative complications were associated with some form of thrombophilia. This study suggests that thrombophilia may play an important role in the pathogenesis of V-TOS and may be a determinant of the success of surgical decompression. Clotting disorders should therefore be aggressively evaluated in this patient population and can improve therapeutic outcome.

Impact of Postoperative Duplex Surveillance after Radiofrequency Ablation of the Greater Saphenous Vein

Purpose Radiofrequency ablation (RFA) is an effective therapeutic option for the treatment of greater saphenous vein (GSV) insufficiency; however, recent reports have begun to document an associated incidence of postprocedural deep venous thrombosis (DVT) of up to 16%. We evaluated our incidence of DVT after RFA and the role of venous duplex ultrasonography (VUS) in the assessment and treatment of GSV reflux. Methods During a 17-month period, 62 lower extremities with symptomatic GSV reflux were evaluated by VUS in 51 patients (74% women; mean age 51 years, range 25–83 yrs). Clinical history and examination focusing on risk factors for venous insufficiency and DVT were obtained along with a complete preoperative bilateral lower-extremity VUS in all patients. All procedures were completed by performing an intraoperative VUS to confirm patency of the GSV and common femoral veins before and after RFA. All patients received outpatient complete lower-extremity VUS within 5 days of the procedure to assess technical success of the procedure and superficial and deep venous patency. Results Fifty (98%) of patients completed RFA, with one patient undergoing high ligation of the GSV because of our inability to pass a guidewire and catheter into the proximal GSV. Duplex ultrasound confirmed successful RFA of the GSV in all limbs treated. Stab phlebectomy was performed in 33 (53%) limbs for associated clusters of large varicose veins. Two postoperative DVTs occurred (2/62,3.2%), both of which were identified as a floating thrombus in the common femoral vein and which subsequently were treated with percutaneous catheter-directed suction thrombectomy without the need for extended anticoagulation therapy. Conclusion Duplex venous scanning is an important component in the diagnosis and treatment of GSV insufficiency. VUS not only is necessary to direct the success of these catheter-based ablative procedures but is mandatory to confirm the absence of extended DVT after the procedure is completed. Our series has recorded a relatively low incidence of DVT and demonstrates that early recognition and aggressive treatment of nonocclusive common femoral DVT after RFA can obviate the need for long-term anticoagulation and potentially the sequelae of deep venous thrombosis.

Mitral Valve Replacement With Ross II Technique: Initial Experience

Pulmonary autograft mitral valve replacement (PA-MVR) was introduced clinically by Ross in 1967, but has been rarely utilized in North America and Europe. The aim of this study is to review our early experience with PA-MVR. Since June 2002, 8 patients (7 female and 1 male) between 12 to 46 years of age with outgrown mechanical valves (n = 3) failed MV repair for rheumatic or congenital MV disease (n = 4) and irreparable bileaflet myxoid prolapse (n = 1), underwent PA-MVR. The pulmonary autograft was harvested and replaced using a pulmonary homograft. The autografts were mounted within a woven Dacron graft 6-8 mm greater in diameter than the autograft annulus diameter on a preoperative echocardiogram. The graft's external surface was covered with fresh autologous pericardium. There were no deaths. Intraoperative echocardiography confirmed a mean MV gradient of 4 mm Hg with trivial (n = 7) or mild (n = 1) regurgitation. Follow-up (range, 13 to 36 months) echocardiography in 4 patients showed no increase in MV gradient or regurgitation. One patient with severe myxoid degeneration and one patient with rheumatic disease, both with systemic hypertension, developed progressive regurgitation due to stretching of a single autograft leaflet producing prolapse. One patient developed a moderate gradient due to retention of excessive native mitral leaflet and subannular chordal tissue. Three of 4 patients have required PA-MVR replacement with mechanical valves 6 to 14 months post-PA-MVR. One asymptomatic patient with mild to moderate mitral regurgitation is being followed after treatment of her systemic hypertension. Pulmonary autograft mitral valve replacement offers selected patients a potentially lifelong autologous valve without the need for long-term anticoagulation. The PA-MVR technique deserves careful consideration in younger patients in sinus rhythm. Postoperative systemic hypertension should be treated aggressively to prevent excessive stress on the pulmonary autograft particularly in the early postoperative months.

Significant arrhythmias associated with Interleukin-2 therapy

2588 Background: A side effects of Interleukin-2 (IL-2) is the vascular leak syndrome. High dose IL-2 produces a reduction of mean arterial pressure and systemic vascular resistance as well as increased heart rate and cardiac output similar to early septic shock. Cardiac arrhythmias have been reported in 14–21% of the patients undergoing IL-2 therapy. Methods: A retrospective study of 92 patients treated at OLMMC with IL-2 for renal cell carcinoma and or melanoma in 2003was done. Patients age ranged from 24 to 74 years (mean of 56 years). Eligibility criteria included normal left ventricular systolic function, normal pulmonary function tests, normal stress test (no evidence of cardiac ischemia), normal renal function, resected locally advance or metastatic renal cell carcinoma, no prior systemic therapy and excellent organ function. All patients treated with IL-2 either high dose or intermediate dose were monitored. EKGs performed before initial infusion demonstrated normal sinus rhythm. Results: Patients included 52 male (56.6%) and 40 females (43.4%). Ten male and eight female patients developed cardiac arrhythmias. Eight patients had AF (8.7%), 8 patients had narrow complex supraventricular tachycardia (8.7%), 2 patients had ventricular tachycardia (0.2%). AF was treated with iv and/or po diltiazam. SVT was treated with iv diltiazem and digoxin; VT was treated with iv procainamide, diltiazam and digoxin. All arrhythmias resolved. Among the 15 patients treated with high dose IL-2, 6 (6.5%) developed AF, 2 (0.2%) developed VT, and 7 (46.6%) developed SVT. Two patients treated with intermediate dose IL-2 developed AF, and 1 developed SVT. The most striking electrolyte imbalances were hyperkalemia and hypercalcemia, although below parameters for arrhythmias. Conclusions: 19.56% of patients treated with iv IL-2 showed significant cardiac arrhythmias that necessitated iv and po management. Several patients required po treatment at home, especially the patients with AF. The patients with AF responded to diltiazem with no need for long-term anticoagulation with warfarin. The VT resolved without sequelae. Despite careful cardiac pre-screening, IL-2 can induce Arrythmias thru physiologic pathways. Therefore, cardiac monitoring continues to be necessary. Author Disclosure Employment or Leadership Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Chiron Chiron Chiron

Mitral valve replacement in children: Evolution and outcomes of a 40-year experience

Background. The ideal prosthesis for mitral valve replacement (MVR) in children remains controversial. The study aim was to review of evolution and outcomes of our 40-year experience with MVR in children. Methods. Since 1963, 75 patients (mean age 9.2 years) have undergone a total of 103 MVR operations. The etiology for valve disease was congenital in 55% of patients, rheumatic in 35%, endocarditis in 8%, and myxomatous in 2%. Xenograft bioprosthesis ( n = 13) and mechanical valves ( n = 58) were used in 71 patients at initial MVR. Since 2002, four patients have undergone MVR using a pulmonary autograft (Ross MVR). Results. Hospital mortality was 9%. Mean follow-up was 7.8 years (range; 2 months to 30 years). Twenty-three patients required reoperations (34%) after the initial MVR. Actuarial freedom from reoperation at 30 years was 47%. There were 16 late deaths and four patients underwent heart transplantation. Overall 30-year survival was 69%. Mortality for children under 2 years versus over 2 years was 47% versus 26% ( P = 0.02), for atrioventricular septal defect versus other pathology mortality was 54% versus 26% ( P = 0.05), and for those operated before versus after 1980 it was 57% versus 20% ( P = 0.003). Conclusions. MVR is the only surgical option for nonrepairable mitral valve in children. Until recently we have favored mechanical MVR for children with failed reconstructive surgery. Our recent experience with the Ross MVR and aortic homograft MVR has allowed us to offer select patients the possibility of a more durable tissue valve without the need for long-term anticoagulation. The Ross MVR is particularly attractive in young female patients.

A perspective on rate control in the treatment of atrial fibrillation

Until recently, the standard approach to therapy of atrial fibrillation (AF) in most cases was restoration and maintenance of sinus rhythm (rhythm control). Although difficult to accomplish, and associated with potential serious adverse effects of antiarrhythmic agents, this therapeutic approach was influenced by the belief that rhythm control was associated with better survival, fewer symptoms, better exercise tolerance, lower risk of stroke, better quality of life, and absence of need for long-term anticoagulation. However, four clinical trials comparing rate control with rhythm control have failed to demonstrate these advantages, indicating that rate control should be considered a legitimate primary therapeutic option, particularly in patients at risk for stroke. Pursuit of rate or rhythm control should be decided on a case-by-case basis.

Patent foramen ovale and hypercoagulability as combined risk factors for stroke

The presence of a patent foramen ovale (PFO) is associated with a high incidence of cryptogenic stroke. Hypercoagulable states contribute to venous thromboembolism. The combination of both conditions may greatly increase the risk of stroke, and may indicate the need for long term anticoagulation. This study aimed to determine the incidence of both risk factors (PFO and hypercoagulable state) in a cohort of patients admitted with the diagnosis of stroke. We performed a retrospective chart review of 2028 consecutive patients admitted to the Massachusetts General Hospital through the emergency room who received an initial triage diagnosis of cerebrovascular event between October 1, 1994 and March 17, 1999. Of the 645 patients who had an echocardiogram searching for atrial shunting, 172 (26.7%) had a documented PFO. Of 472 patients who had a hypercoagulability study, an abnormality was identified in 112 (23.7%). Of the 280 patients who had both procedures, 14 (5.0%) were found to have both a PFO and a hypercoagulation abnormality; this represents 17.3% (14/81) of the patients with PFO who underwent a hypercoagulability study. In comparison, 22.1% (44/199) of patients without PFO had a hypercoagulation abnormality. In our series, the incidence of PFO was comparable to that of other reported series. A hypercoagulation abnormality was detected in one fourth of patients who underwent a diagnostic study. The frequency of hypercoagulation abnormality was not higher among patients with a PFO compared to patients without one.