(Stroke. 2001;32:803.)
© 2001 American Heart Association, Inc.
Comments, Opinions, and Reviews |
Atrial Fibrillation and Stroke
Concepts and Controversies
From the Department of Medicine (Neurology) (R.G.H.), University of Texas Health Sciences Center (San Antonio); and The Zena and Michael A. Wiener Cardiovascular Institute (J.L.H.), Mt Sinai Medical Center, New York, NY.
Correspondence to Robert G. Hart, MD, Department of Medicine (Neurology), University of Texas Health Science Center, MSC 7883, 7703 Floyd Curl Dr, San Antonio, TX 78229-3900. E-mail hartr@uthscsa.edu
Key Words: anticoagulants • aspirin • atrial fibrillation • cerebral embolism • cerebrovascular disorders • stroke
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Introduction |
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In 1985, patients with nonvalvular atrial fibrillation (AF) first entered randomized clinical trials that tested antithrombotic therapies for stroke prevention.1 2 3 Since then, >12 000 AF patients have been included in 25 trials that involved >40 randomized treatment comparisons (Table 1
). During this interval, we reviewed the
pathogenesis and prevention of stroke in AF patients in 2 previous
editorials in
Stroke.4 5
Here, we offer commentary on selected concepts and
controversies.
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The prevalence of AF increases with age, affecting 
5% of
people at age 70 years. Although AF-associated stroke can occur at any
age, it is predominantly a problem of the elderly. The median age of AF
patients with stroke in population-based studies is 75 years; more
than half are women. In people over age 75, AF is the most important
single cause of ischemic stroke. This
epidemiology is relevant when considering
stroke prevention, because the risks of and ability to sustain
preventive therapies are special problems for the very
elderly.
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Left Atrial Appendage Thrombi |
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The left atrial appendage is a unique substrate for stroke. It is an elongated cul-de-sac lined with endothelium, a remnant of the embryonic atrium, trabeculated by pectinate muscles (Figure 1
). The contractility of the
appendage is reduced in AF, but the degree varies widely and is an
important determinant of stasis and thrombus formation. In AF patients,
atrial thrombi almost always originate in the appendage, rather than in
the smooth-walled atrium proper, and are not reliably detected with
transthoracic echocardiography.
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