Download PDF
Thromb Haemost 2016; 116(02): 206-219
DOI: 10.1160/TH15-12-0923
Review Article
Schattauer GmbH

Left atrial size and risk of stroke in patients in sinus rhythm

A systematic review
Thure Filskov Overvad
1   Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
2   Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
,
Peter Brønnum Nielsen
1   Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
,
Torben Bjerregaard Larsen
1   Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
2   Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
,
Peter Søgaard
2   Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
› Author Affiliations
Further Information

Publication History

Received: 03 December 2015

Accepted after minor revision: 08 April 2016

Publication Date:
10 November 2017 (online)

    Permissions and Reprints

Summary

Little is known about the risk of stroke associated with left atrial enlargement in patients in sinus rhythm, and whether such patients may have an unmet need for thromboprophylaxis. In this systematic review we summarise the existing evidence concerning left atrial size and risk of stroke in patients in sinus rhythm. Nine cohort studies were identified, analysing a total of 67,875 participants and 3,093 stroke outcomes. Rates of stroke per 100 person-years in patients with left atrial enlargement and in sinus rhythm ranged from 0.59 in a population-based cohort to 2.06 in patients referred for echocardiography. All studies reported a higher risk of stroke with larger/enlarged left atrium compared to smaller/normal sized left atrium. Two studies found indications of modification by sex, with only positive associations observed in women. Left atrial enlargement may represent an important predictor of stroke across a variety of patient populations in sinus rhythm. The underlying aetiology explaining this observed higher risk is likely to be multifactorial and not confined to a potential direct effect of left atrial enlargement on thromboembolic risk. Formal stroke risk stratification among patients with left atrial enlargement may further help identify patients who stand to gain from preventive antithrombotic therapy.

Supplementary Material to this article is available online at www.thrombosis-online.com.

Keywords

Left atrial size - left atrial enlargement - sinus rhythm - stroke/prevention - thromboembolism

 

  • References

  • 1 Abhayaratna WP. et al. Left atrial size: physiologic determinants and clinical applications. J Am Coll Cardiol 2006; 47: 2357-2363.
    CrossrefPubMedGoogle Scholar
  • 2 Hoit BD.. Left atrial size and function: role in prognosis. J Am Coll Cardiol 2014; 63: 493-505.
    CrossrefPubMedGoogle Scholar
  • 3 Tani T. et al. Left atrial volume and the risk of paroxysmal atrial fibrillation in patients with hypertrophic cardiomyopathy. J Am Soc Echocardiogr 2004; 17: 644-648.
    CrossrefPubMedGoogle Scholar
  • 4 Tsang TS. et al. Left atrial volume: important risk marker of incident atrial fibrillation in 1655 older men and women. Mayo Clin Proc 2001; 76: 467-475.
    CrossrefPubMedGoogle Scholar
  • 5 Psaty BM. et al. Incidence of and risk factors for atrial fibrillation in older adults. Circulation 1997; 96: 2455-2461.
    CrossrefPubMedGoogle Scholar
  • 6 Vaziri SM. et al. Echocardiographic predictors of nonrheumatic atrial fibrillation. The Framingham Heart Study. Circulation 1994; 89: 724-730.
    CrossrefPubMedGoogle Scholar
  • 7 Camm JA. et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Eur Heart J 2012; 33: 2719-2747.
    CrossrefPubMedGoogle Scholar
  • 8 Benjamin EJ. et al. Left atrial size and the risk of stroke and death: the Framingham Heart Study. Circulation 1995; 92: 835-841.
    CrossrefPubMedGoogle Scholar
  • 9 Gardin JM. et al. M-Mode echocardiographic predictors of six- to seven-year incidence of coronary heart disease, stroke, congestive heart failure, and mortality in an elderly cohort (The Cardiovascular Health Study).. Am J Cardiol 2001; 87: 1051-1057.
    CrossrefPubMedGoogle Scholar
  • 10 Barnes ME. et al. Left atrial volume in the prediction of first ischemic stroke in an elderly cohort without atrial fibrillation. Mayo Clin Proc 2004; 79: 1008-1014.
    CrossrefPubMedGoogle Scholar
  • 11 Mancia G. et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2013; 34: 2159-2219.
    CrossrefPubMedGoogle Scholar
  • 12 Patel DA. et al. Clinical implications of left atrial enlargement: a review. Ochsner J 2009; 9: 191-196.
    PubMedGoogle Scholar
  • 13 Moher D. et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Br Med J 2009; 339: b2535.
    CrossrefPubMedGoogle Scholar
  • 14 Cochrane Bias Methods Group.. Tool to assess the risk of bias in cohort studies. Available at: http://bmg.cochrane.org/sites/bmg.cochrane.org/files/uploads/ Tool to Assess Risk of Bias in Cohort Studies.pdf. December 2, 2015.
    PubMedGoogle Scholar
  • 15 Nunes MC, Barbosa MM, Ribeiro AL. et al. Ischemic cerebrovascular events in patients with Chagas cardiomyopathy: a prospective follow-up study. J Neurol Sci 2009; 278: 96-101.
    CrossrefPubMedGoogle Scholar
  • 16 Lai C-L. et al. Left atrial dimension and risk of stroke in women without atrial fibrillation: the Chin-Shan Community Cardiovascular Cohort study. Echocardiography 2011; 28: 1054-1060.
    CrossrefPubMedGoogle Scholar
  • 17 Bouzas-Mosquera A. et al. Left atrial size and risk for all-cause mortality and ischemic stroke. Can Med Assoc J 2011; 183: E657-664.
    CrossrefPubMedGoogle Scholar
  • 18 Karas MG. et al. Incremental value of biochemical and echocardiographic measures in prediction of ischemic stroke: the Strong Heart Study. Stroke 2012; 43: 720-726.
    CrossrefPubMedGoogle Scholar
  • 19 Wong JM. et al. Relation of left atrial dysfunction to ischemic stroke in patients with coronary heart disease (from the Heart and Soul study). Am J Cardiol 2014; 113: 1679-1684.
    CrossrefPubMedGoogle Scholar
  • 20 Mahabadi AA. et al. Association of computed tomography-derived left atrial size with major cardiovascular events in the general population: the Heinz Nixdorf Recall Study. Int J Cardiol 2014; 174: 318-323.
    CrossrefPubMedGoogle Scholar
  • 21 Pierdomenico SD. et al. Left atrial enlargement and risk of ischemic stroke in elderly treated hypertensive patients. Am J Hypertens 2014; 27: 1179-1184.
    CrossrefPubMedGoogle Scholar
  • 22 Douglas PS. et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography. J Am Coll Cardiol 2011; 57: 1126-1166.
    CrossrefPubMedGoogle Scholar
  • 23 Khoo CW. et al. Assessment of left atrial volume: A focus on echocardiographic methods and clinical implications. Clin Res Cardiol 2011; 100: 97-105.
    CrossrefPubMedGoogle Scholar
  • 24 Andersen JS. et al. Atrial fibrillation and left atrial enlargement: cause or effect? J Intern Med. 1991 229. 253-256.
    PubMedGoogle Scholar
  • 25 Ganesan AN. et al. The impact of atrial fibrillation type on the risk of thromboembolism, mortality, and bleeding: a systematic review and meta-analysis. Eur Heart J. 2016 Epub ahead of print.
    PubMedGoogle Scholar
  • 26 Di Tullio MR. et al. Left atrial size and the risk of ischemic stroke in an ethnically mixed population. Stroke 1999; 30: 2019-2024.
    CrossrefPubMedGoogle Scholar
  • 27 Kim BS. et al. Relationship between left atrial size and stroke in patients with sinus rhythm and preserved systolic function. Korean J Intern Med 2009; 24: 24-32.
    CrossrefPubMedGoogle Scholar
  • 28 Piotrowski G. et al. Left atrial size in hypertension and stroke. J Hypertens 2011; 29: 1988-1993.
    CrossrefPubMedGoogle Scholar
  • 29 Russo C. et al. LA volumes and reservoir function are associated with subclinical cerebrovascular disease: the CABL (Cardiovascular Abnormalities and Brain Lesions) study. JACC Cardiovasc Imaging 2013; 6: 313-323.
    CrossrefPubMedGoogle Scholar
  • 30 Lip GY, Gibbs CR.. Does heart failure confer a hypercoagulable state? Virchow's triad revisited. J Am Coll Cardiol 1999; 33: 1424-1426.
    CrossrefPubMedGoogle Scholar
  • 31 Watson T. et al. Mechanisms of thrombogenesis in atrial fibrillation: Virchow's triad revisited. Lancet 2009; 373: 155-166.
    CrossrefPubMedGoogle Scholar
  • 32 Bakalli A. et al. Prevalence of left chamber cardiac thrombi in patients with dilated left ventricle at sinus rhythm: The role of transesophageal echocardiography. J Clin Ultrasound 2013; 41: 38-45.
    CrossrefPubMedGoogle Scholar
  • 33 Stritzke J. et al. The aging process of the heart: Obesity is the main risk factor for left atrial enlargement during aging. The MONICA/KORA (Monitoring of Trends and Determinations in Cardiovascular Disease/Cooperative Research in the Region of Augsburg) Study. J Am Coll Cardiol 2009; 54: 1982-1989.
    CrossrefPubMedGoogle Scholar
  • 34 Katayama T. et al. Factors contributing to left atrial enlargement in adults with normal left ventricular systolic function. J Cardiol 2010; 55: 196-204.
    CrossrefPubMedGoogle Scholar
  • 35 Mäuser W. et al. Sleep disordered breathing is an independent risk factor for left atrial enlargement in patients with congestive heart failure. Int J Cardiol 2013; 167: 2323-2324.
    CrossrefPubMedGoogle Scholar
  • 36 Tadic M, Cuspidi C.. The influence of type 2 diabetes on left atrial remodeling. Clin Cardiol 2015; 38: 48-55.
    CrossrefPubMedGoogle Scholar
  • 37 Lewington S. et al. Age-specific relevance of usual blood pressure to vascular mortality: A meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360: 1903-1913.
    CrossrefPubMedGoogle Scholar
  • 38 Strazzullo P. et al. Excess body weight and incidence of stroke: meta-analysis of prospective studies with 2 million participants. Stroke 2010; 41: e418-426.
    CrossrefPubMedGoogle Scholar
  • 39 Peters SA. et al. Diabetes as a risk factor for stroke in women compared with men: a systematic review and meta-analysis of 64 cohorts, including 775 385 individuals and 12 539 strokes. Lancet 2014; 383: 1973-1980.
    CrossrefPubMedGoogle Scholar
  • 40 Lyons OD, Ryan CM.. Sleep apnea and stroke. Can J Cardiol 2015; 31: 918-927.
    CrossrefPubMedGoogle Scholar
  • 41 Fuster V, Halperin JL.. Left ventricular thrombi and cerebral embolism. N Engl J Med 1989; 320: 392-394.
    CrossrefPubMedGoogle Scholar
  • 42 Arboix A, Alió J.. Cardioembolic stroke: clinical features, specific cardiac disorders and prognosis. Curr Cardiol Rev 2010; 6: 150-161.
    CrossrefPubMedGoogle Scholar
  • 43 Ruwald MH. et al. Left ventricular ejection fraction normalization in cardiac re-synchronization therapy and risk of ventricular arrhythmias and clinical outcomes: Results from the MADIT-CRT trial. Circulation 2014; 130: 2278-2287.
    CrossrefPubMedGoogle Scholar
  • 44 Tiwari S. et al. Association between diastolic dysfunction and future atrial fibrillation in the Tromsø Study from 1994 to 2010. Heart 2015; 101: 1302-1308.
    CrossrefPubMedGoogle Scholar
  • 45 Mozaffarian D. et al. Heart disease and stroke statistics--2015 update: A report from the American Heart Association. Circulation 2015; 131: e29-322.
    CrossrefPubMedGoogle Scholar
  • 46 Eckman MH. et al. Moving the tipping point: the decision to anticoagulate patients with atrial fibrillation. Circ Cardiovasc Qual Outcomes 2011; 4: 14-21.
    CrossrefPubMedGoogle Scholar
  • 47 Lip GY. et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on Atrial Fibrillation. Chest 2010; 137: 263-272.
    CrossrefPubMedGoogle Scholar
  • 48 Melgaard L. et al. Assessment of the CHA2DS2-VASc score in predicting ischemic stroke, thromboembolism, and death in patients with heart failure with and without atrial fibrillation. J Am Med Assoc 2015; 314: 1030-1038.
    CrossrefPubMedGoogle Scholar
  • 49 Shin H-Y. et al. Relation between left atrial enlargement and stroke subtypes in acute ischemic stroke patients. J Cerebrovasc Endovasc Neurosurg 2013; 15: 131-136.
    CrossrefPubMedGoogle Scholar
  • 50 Shaikh Q. et al. Left atrial volumes and associated stroke subtypes. BMC Neurol 2013; 13: 149.
    CrossrefPubMedGoogle Scholar
  • 51 Adams H. et al. Classification of subtype of acute ischemic stroke. Stroke 1993; 23: 35-41.
    PubMedGoogle Scholar
  • 52 Hart RG. et al. Meta-analysis: Antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 2007; 146: 857-867.
    CrossrefPubMedGoogle Scholar
  • 53 Rajkumar CA, Floyd CN, Ferro A.. Antiplatelet therapy as a modulator of stroke aetiology: a meta-analysis. Br J Clin Pharmacol 2015; 80: 331-341.
    CrossrefPubMedGoogle Scholar
  • 54 Healey JS, Sandhu RK.. Are we ready for mass screening to detect atrial fibrillation?. Circulation 2015; 131: 2167-2168.
    CrossrefPubMedGoogle Scholar
  • 55 Tsang TS. et al. Effects of quinapril on left atrial structural remodeling and arterial stiffness. Am J Cardiol 2006; 97: 916-920.
    CrossrefPubMedGoogle Scholar
  • 56 Masaki M. et al. Long-term effects of irbesartan on plasma aldosterone concentration and left atrial volume in hypertensive patients. J Cardiol 2014; 63: 205-210.
    CrossrefPubMedGoogle Scholar
  • 57 Tsang TS. et al. Prediction of cardiovascular outcomes with left atrial size: is volume superior to area or diameter?. J Am Coll Cardiol 2006; 47: 1018-1023.
    CrossrefPubMedGoogle Scholar
  • 58 Lang RM. et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015; 28: 1-39.
    CrossrefPubMedGoogle Scholar
  • 59 Quintana M. et al. Assessment of atrial regional and global electromechanical function by tissue velocity echocardiography: a feasibility study on healthy individuals. Cardiovasc Ultrasound 2005; 3: 4.
    CrossrefPubMedGoogle Scholar
  • 60 Kuchynka P. et al. The role of magnetic resonance imaging and cardiac computed tomography in the assessment of left atrial anatomy, size, and function. Biomed Res Int 2015; 2015: 247865.
    PubMedGoogle Scholar
  • 61 Leischik R. et al. Echocardiographic evaluation of left atrial mechanics: Function, history, novel techniques, advantages, and pitfalls. Biomed Res Int 2015; 2015: 765-921.
    PubMedGoogle Scholar