From Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis (W.B., S.D., A.T.H.); Department of Medicine, McMaster University, Hamilton, Ontario (S.J.C., S.C., J.P., J.W.E., S.Y.); Mt. Sinai School of Medicine, New York (J.L.H.); Division of Cardiology, Minneapolis Veterans Administration Medical Center, MN (S.A.); Lankenau Institute for Medical Research, Wynnewood, PA (M.D.E.); and Uppsala Clinical Research Center, Sweden (L.G.W.).
Circulation. 2015 Sep 1;132(9):796-803. doi: 10.1161/CIRCULATIONAHA.114.013243. Epub 2015 Jul 29.
Nonvalvular atrial fibrillation is a major cause of thromboembolic events. In comparison with atrial fibrillation-related stroke, extracranial systemic embolic events (SEEs) remain poorly defined.
All suspected SEEs reported among 37 973 participants of 4 large contemporary randomized clinical trials of anticoagulation in atrial fibrillation were independently readjudicated for clinical and objective evidence of sudden loss of perfusion of a limb or organ. Over 91 746 patient-years of follow-up, 221 SEEs occurred in 219 subjects. The SEE incidence was 0.24 of 100 and stroke incidence was 1.92 of 100 patient-years. In comparison with patients with stroke, those with SEE were more often female (56% versus 47%; P=0.01) and had comparable mean age (73.1±8.5 versus 73.5±8.8 years; P=0.57) and mean CHADS2 scores (2.4±1.3 versus 2.5±1.2; P=0.33). SEEs 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 25% died. Thirty-day mortality was greater after visceral-mesenteric than lower- or upper-extremity SEE (55%, 17%, and 9%, respectively, P≤0.0001). The relative risk of death throughout follow-up was 4.33 (95% confidence interval, 3.29-5.70) after SEE versus 6.79 (95% confidence interval, 6.22-7.41) after stroke in comparison with patients without either event.
SEE constituted 11.5% of clinically recognized thromboembolic events in patients with atrial fibrillation and was associated with high morbidity and mortality. SEE mortality was comparable to that of ischemic stroke and varied by anatomic site.
非瓣膜性心房颤动是血栓栓塞事件的主要原因。与房颤相关的脑卒中相比，颅外全身栓塞事件（SEE）仍未得到充分定义。
在 4 项大型当代抗凝心房颤动随机临床试验的 37973 名参与者中报告的所有疑似 SEE 均进行了独立重新评估，以确定肢体或器官突然灌注丧失的临床和客观证据。在超过 91746 患者年的随访中，219 名患者发生了 221 例 SEE。SEE 的发生率为每 100 人中 0.24 例，脑卒中的发生率为每 100 患者年 1.92 例。与脑卒中患者相比，SEE 患者更多为女性（56%比 47%；P=0.01），年龄相当（73.1±8.5 岁比 73.5±8.8 岁；P=0.57），CHADS2 评分相当（2.4±1.3 分比 2.5±1.2 分；P=0.33）。SEE 更常累及下肢（58%），而内脏-肠系膜（31%）或上肢（10%）较少。SEE 相关治疗仅在 5%的患者中涉及门诊评估，30%的患者住院但无治疗措施，60%的患者接受了血管内或手术干预，5%的患者进行了截肢。在 30 天内，54%的患者完全康复，20%的患者存活但有残疾，25%的患者死亡。内脏-肠系膜 SEE 后 30 天死亡率高于下肢或上肢 SEE（分别为 55%、17%和 9%，P≤0.0001）。与无任何一种事件的患者相比，整个随访期间 SEE 后死亡的相对风险为 4.33（95%置信区间，3.29-5.70），而脑卒中后为 6.79（95%置信区间，6.22-7.41）。
在房颤患者中，SEE 占临床确认的血栓栓塞事件的 11.5%，与高发病率和死亡率相关。SEE 死亡率与缺血性脑卒中相当，且与解剖部位有关。
