Augusta University, GA, USA.
J Investig Med High Impact Case Rep. 2023 Jan-Dec;11:23247096231165740. doi: 10.1177/23247096231165740.
Atrial fibrillation (AF) can cause thrombi formation and subsequent emboli deposition in systemic arteries, leading to various organ ischemia and infarction. Anticoagulation therapy can reduce the risk of thrombus formation and embolization, and is initiated based on a patient's risk score, which is frequently estimated with the CHA2DS2-VASc score. We present a case of thromboembolism (TE) where a low CHA2DS2-VASc score suggested a low-moderate risk of systemic embolization, but an elevated plasma D-dimer value prompted further investigation which revealed an intracardiac thrombus with renal embolism. The patient is a 63-year-old male with past medical history of hypertension and AF treated with ablation 2 years prior presenting with sharp right flank pain of 5-hour duration. Primary workup and imaging were unrevealing at the time, and a low CHA2DS2-VASc score was suggestive of aspirin therapy. However, an elevated D-dimer of 289 ng/mL and a transient increase in creatinine pointed to possible etiology of embolic origin. The diagnosis was confirmed with computed tomography (CT) with contrast and transesophageal echocardiogram, revealing renal infarcts and the source of the emboli, respectively. The patient was treated with heparin and transitioned to apixaban prior to discharge with full resolution of symptoms. Through this case, we wish to show D-dimer's predictive value of TE, as well as its potential benefit in risk assessment in patients with AF.
心房颤动（AF）可导致血栓形成，并随后在体动脉中沉积栓子，导致各种器官缺血和梗死。抗凝治疗可降低血栓形成和栓塞的风险，并根据患者的风险评分开始治疗，该评分通常使用 CHA2DS2-VASc 评分来估计。我们报告了一例血栓栓塞（TE）病例，其中低 CHA2DS2-VASc 评分提示全身性栓塞的中低度风险，但升高的血浆 D-二聚体值提示进一步检查，发现伴有肾栓塞的心内血栓。该患者为 63 岁男性，既往有高血压和 AF 病史，2 年前接受消融治疗，现因持续 5 小时的锐性右侧腰痛就诊。当时的初步检查和影像学检查均无异常，低 CHA2DS2-VASc 评分提示可使用阿司匹林治疗。然而，升高的 D-二聚体值（289ng/ml）和肌酐的一过性升高提示可能为栓塞性病因。CT 增强和经食管超声心动图诊断证实为肾梗死和栓子来源。患者接受肝素治疗，出院前转为阿哌沙班治疗，症状完全缓解。通过这个病例，我们希望展示 D-二聚体对 TE 的预测价值，以及其在 AF 患者风险评估中的潜在益处。
