Ann Intern Med. 1998 Apr 15;128(8):639-47. doi: 10.7326/0003-4819-128-8-199804150-00005.
Transesophageal echocardiography (TEE) visualizes potential sources of embolism in patients with atrial fibrillation, but the clinical significance of TEE findings has not been prospectively established.
To define TEE predictors of stroke in patients with atrial fibrillation and to examine response to antithrombotic therapy.
Prospective correlation of TEE findings at study entry with subsequent ischemic stroke during 1.1-year mean follow-up of participants in a randomized trial.
18 echocardiography laboratories.
382 patients with atrial fibrillation at high risk for thromboembolism.
Adjusted-dose warfarin (international normalized ratio, 2 to 3) or low-intensity warfarin (international normalized ratio, 1.2 to 1.5) plus aspirin (325 mg/d).
Size of left atrium and left atrial appendage, flow velocity, spontaneous echocardiographic contrast, thrombus, and plaque on the aortic arch.
23 ischemic strokes occurred. In patients with dense spontaneous echocardiographic contrast (20%), the rate of stroke was 18.2% per year with combination therapy (2.9 times the rate in patients without this finding; P = 0.06) and 4.5% per year with adjusted-dose warfarin (P = 0.09 for rate reduction). Appendage thrombus, detected in 10% of patients, was associated with dense spontaneous echocardiographic contrast (P < 0.001), was seen more frequently after 2 weeks of combination therapy (15%) than after 2 weeks of adjusted-dose warfarin (4%) (P = 0.004), and tripled the overall rate of stroke (P = 0.04). Patients with complex aortic plaque (35%) had a fourfold increased rate of stroke compared with plaque-free patients (P = 0.005); adjusted-dose warfarin decreased risk by 75% (P = 0.02). Dense spontaneous echocardiographic contrast and complex aortic plaque were independent of each other as predictors of thromboembolism.
In high-risk patients with atrial fibrillation, subsequent rates of thromboembolism are correlated with dense spontaneous echocardiographic contrast, thrombus of the atrial appendage, and aortic plaque. Adjusted-dose warfarin reduces the rate of stroke among patients with dense contrast and complex plaque. In patients with atrial fibrillation, the pathogenesis of stroke is multifactorial, and warfarin seems effective for the diverse mechanisms.
经食管超声心动图（TEE）可显示心房颤动患者潜在的栓子来源，但TEE检查结果的临床意义尚未经过前瞻性验证。
确定心房颤动患者发生卒中的TEE预测指标，并研究抗栓治疗的反应。
在一项随机试验中，对研究开始时TEE检查结果与参与者1.1年平均随访期间随后发生的缺血性卒中进行前瞻性相关性研究。
18个超声心动图实验室。
382例有血栓栓塞高风险的心房颤动患者。
调整剂量的华法林（国际标准化比值，2至3）或低强度华法林（国际标准化比值，1.2至1.5）加阿司匹林（325mg/d）。
左心房和左心耳大小、血流速度、自发超声造影、血栓以及主动脉弓上的斑块。
发生23例缺血性卒中。在有密集自发超声造影的患者（20%）中，联合治疗组每年的卒中发生率为18.2%（是无此表现患者发生率的2.9倍；P=0.0****），调整剂量华法林组每年的卒中发生率为4.5%（降低发生率P=0.09）。10%的患者检测到心耳血栓，其与密集自发超声造影相关（P<0.001），联合治疗2周后（15%）比调整剂量华法林治疗2周后（4%）更常出现（P=0.004），且使总体卒中发生率增加两倍（P=0.04）。有复杂主动脉斑块的患者（35%）与无斑块患者相比，卒中发生率增加四倍（P=0.005）；调整剂量华法林使风险降低75%（P=0.02）。密集自发超声造影和复杂主动脉斑块作为血栓栓塞的预测指标相互独立。
在高危心房颤动患者中，随后的血栓栓塞发生率与密集自发超声造影、心耳血栓和主动脉斑块相关。调整剂量的华法林可降低有密集造影和复杂斑块患者的卒中发生率。在心房颤动患者中，卒中的发病机制是多因素的，华法林似乎对多种机制有效。
