Natural History of Intra-cardiac Thrombus in Stroke/TIA Patients
Background Intra-cardiac thrombus is a potential source of embolus leading to ischemic cerebrovascular event. The natural history of intra-cardiac thrombus is not known. Objectives To examine the natural history of intra-cardiac thrombus detected by TEE in stroke/TIA patients. Methods Eighty-one patients with recent stroke/TIA underwent sequential TEE evaluations at ≤7 days and 9 months from the symptom onset to detect intra-cardiac thrombus (mean age 60, 39 males and 60 black). The TEEs were recorded on VHS videotape and systematically evaluated by two blinded cardiologists for evidence and location of intra-cardiac thrombus (λ=0.72). In case of a disagreement it was adjudicated by a third blinded cardiologist. The stroke risk factors and stroke preventive medications were recorded in patients with and without intracardiac thrombus and compared using χ2 test. Results An intra-cardiac thrombus was found in the initial TEE in 18 (22%) patients (2 in left atrium, 13 in left atrial appendage, 3 in left ventricle) and in the follow-up 9 month TEE in 9 (11%) patients (8 in left atrial appendage, 1 in left ventricle). The intracardiac thrombus had disappeared in 14 (78%) patients in a period of 9 months (2 in left atrium, 9 in left atrial appendage and 3 in left ventricle). Disappearance of intracardiac thrombus correlated strongly with patients anticoagulated with Warfarin (p<0.0001). A new intracardiac thrombus was detected only on the 9 month TEE in 5 (6%) patients (5 in the left atrial appendage, none in the left atrium or left ventricle). The patients with new intracardiac thrombus were significantly (p=0.02) older (mean±SD=70±7 yrs) as compared to those without (59±12 yrs). Three out of five patients with new cardiac thrombus were felt to have small vessel occlusive disease and were on antiplatelet therapy. Conclusions Anticoagulation with warfarin for 9 months can result in disappearance of intracardiac thrombus in stroke/TIA patients. Anticoagulation with Warfarin may have a therapeutic role in stroke/TIA patients with intracardiac thrombus. Older patients with lacunar strokes and not on anticoagulation are prone to develop an new intracardiac thrombus.