Review
Thromboembolism in Atrial Fibrillation

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Thromboembolism is a severe complication in atrial fibrillation. This overview presents thromboembolic disease as a single entity, ranging from stroke through mesenteric ischemia to acute limb ischemia. The PubMed, Embase, and Cochrane databases were systematically searched for the terms ā€œatrial fibrillationā€ and ā€œthromboembolismā€ in reports published from January 1986 to September 2009. The information of 10 evidence-based practice guideline documents and 61 further sources was systematically extracted. In atrial fibrillation, the average annual stroke risk is increased by 2.3% (lethality 30%). The annual incidence of acute mesenteric ischemia is 0.14% (lethality 70%), and that of acute limb ischemia is 0.4% (lethality 16%). In total, approximately 80% of embolism-related deaths are from stroke and 20% from other systemic thromboembolism. The ischemic symptoms generally have an acute onset but may mimic other diseases, particularly in mesenteric ischemia. Early diagnosis and treatment can limit or even prevent tissue infarction. Guideline-recommended therapy with aspirin or warfarin reduces the thromboembolic risk. Suitable patients may optimize their warfarin therapy by self-monitoring of the international normalized ratio (INR). New oral and parenteral anticoagulants with more stable pharmacokinetics are being developed. In conclusion, atrial fibrillation predisposes to thromboembolism. If ischemic stroke or systemic thromboembolism occurs, early diagnosis and treatment can improve outcomes. The thromboembolic risks are reduced by guideline-adherent antithrombotic therapy with warfarin or aspirin. Future directions may include self-monitoring of the international normalized ratio and novel anticoagulants.

Section snippets

Identification of published research

The PubMed, Embase, and Cochrane databases were searched for the Medical Subject Headings ā€œ(atrial fibrillation) AND (thromboembolism OR embolism OR ischemia OR transient ischemic attack OR stroke)ā€ and related terms in reports published from January 1986 to September 2009, with a focus on more recent publications. Further literature was identified from the reference lists of retrieved reports. This systematic term-driven literature search was intended to find the most reports with direct

AF

The pathogenesis and treatment strategies of AF, such as rate and rhythm control, are covered by other guidelines and publications.1, 2, 16, 17, 18 These treatment strategies, as well as the prevention of AF itself, can contribute to an overall reduction in the risk for thromboembolism. However, thromboembolism may occur even with optimal AF treatment.2, 16

Left atrial thrombus formation

During episodes of AF, cardiac blood flow is reduced, especially in the left atrial appendage, which is the major site of thrombus formation.

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