CARDIOVASCULAR JOURNAL OF AFRICA • Vol 21, No 4, July/August 2010
192
AFRICA
Value of trans-oesophageal echocardiography as a
method of encouraging patients with chronic atrial
fibrillation to use anticoagulation therapy
A BAKALLI, L KAMBERI, G DRAGUSHA, N ZEQIRI, F GASHI, L PREKPALAJ
Summary
Background:
Despite the indisputable role of anticoagulation
therapy for atrial fibrillation (AF) patients at risk for stroke,
anticoagulants remain under-used in everyday clinical prac-
tice. We assumed that by performing trans-oesophageal
echocardiography (TEE) on patients with AF who were not
on anticoagulation treatment prior to the procedure, and by
explaining to them the TEE images obtained, as well as the
possible consequences of these findings, we could convince
patients to start anticoagulation therapy. The main objective
of the study was to assess the examined patients’ adherence
to warfarin therapy over a two-year period.
Methods and results:
We conducted a prospective TEE study
from February 2006 to December 2008 on 70 patients with
chronic AF who were not on anticoagulation treatment.
Mean patient age was 65.85
±
10.02 years and 68.57% were
women. Thrombus in the left atrial appendage was found
in 25 (35.71%) patients. Fifty-four (77.14%) patients had
thrombi or spontaneous echo contrast in at least one of their
supraventricular cavities.
Following the procedure and with detailed explanation
to the patients of their TEE findings, we managed to start
anticoagulation therapy on 60 (85.71%) patients. At the end
of the follow-up period of 23.76
±
2.8 months, 53 (75.71%)
patients remained on warfarin therapy.The rest of the surviv-
ing patients settled for thrombo-prophylaxis with aspirin.
Conclusion:
TEE is a valuable method that, in addition to
its diagnostic possibilities, could also serve as a convincing
visual method of putting atrial fibrillation patients onto an
anticoagulation regimen.
Keywords:
atrial fibrillation, trans-oesophageal echocardiogra-
phy, left atrial appendage thrombus
Submitted 12/9/09, accepted 10/3/10
Cardiovasc J Afr
2010;
21
: 192–194
DOI: CVJ-21.002
The presence of non-valvular atrial fibrillation increases the risk
of thrombo-embolism fivefold.
1
Warfarin has been shown to be
highly beneficial in the prevention of stroke or systemic thrombo-
embolism in moderate- to high-risk patients with chronic atrial
fibrillation. A recent meta-analysis of 29 trials, totalling 28 044
participants, which analysed the role of thrombo-prophylaxis in
atrial fibrillation, showed that adjusted-dose warfarin signifi-
cantly reduced the risk of thrombo-embolic events.
2
Despite the unquestionable role of anticoagulation therapy in
patients with non-valvular atrial fibrillation at moderate to high
risk of stroke, it still remains under-used in clinical practice.
3,4
Studies on clinical practice report that only a quarter to a half
of eligible patients with atrial fibrillation undergo anticoagula-
tion treatment.
5,6
Under-usage of anticoagulation therapy can be
attributed to two main aspects: physician and patient reluctance.
The aim of this study was to perform trans-oesophageal
echocardiography (TEE) in patients with chronic non-valvular
atrial fibrillation who did not take anticoagulation therapy prior
to the procedure, in order to asses the prevalence of atrial throm-
bi and spontaneous echo contrast (SEC) in these patients. The
main purpose was to evaluate their adherence to anticoagulation
therapy after TEE, as well as to assess the morbidity and mortal-
ity associated with atrial fibrillation over a two-year follow-up
period following the TEE procedure. Our hypothesis was that
detection of thrombi or SEC by TEE would serve as a persuasive
tool to convince the patient of the importance of anticoagulation
therapy.
Methods
We conducted a prospective TEE study from February 2006 to
December 2008 on 70 patients with chronic non-valvular atrial
fibrillation at moderate to high risk of stroke, who were not on
anticoagulation therapy. TEE procedures were carried out from
February to October 2006; thereafter these patients regularly
visited an outpatient cardiology ward for a mean period of two
years. The emphasis was on assessment of their adhesion to anti-
thrombotic therapy.
Atrial fibrillation was diagnosed by at least two electrocar-
diograms (ECG), presenting with the absence of P waves before
each QRS complex, and replaced instead by fibrillatory ‘f’waves
varying in size, shape and timing. Patients at moderate to high
risk of stroke were those who, in addition to chronic non-valvular
atrial fibrillation, also suffered from arterial hypertension, diabe-
tes mellitus, vascular disease, heart failure, or previous stroke,
transient ischaemic attack or systemic thrombo-embolic event.
Patient age was also taken into consideration when stratifying
them into moderate or high stroke-risk category.
Comprehensive histories, physical examinations, laboratory
tests, electrocardiograms, transthoracic echocardiography (TTE)
and TEE were performed on all patients included in the study.
Patients who could not tolerate TEE were excluded. Written
consent was obtained from all patients in the study.
Patients were asked specifically if they were aware of the
Department of Cardiology, University Clinical Centre of
Kosova, Prishtine, Kosova
AURORA BAKALLI, MD, MS,
LULZIM KAMBERI, MD, MS
GANI DRAGUSHA, MD, PhD
NEXHMI ZEQIRI, MD, PhD
FITIM GASHI, MD
LAZER PREKPALAJ, MD
