Restricted accessResearch articleFirst published online 1995-4
Left Ventricular Thrombus and the Incidence of Thromboembolism in Patients with Congestive Heart Failure: Can Clinical Factors Identify Patients at Increased Risk?
Left ventricular thrombus is highly prevalent in patients with congestive heart failure, but the incidence of thromboembolic events is low. Reliable clinical indicators of increased thromboembolic risk are not yet available. Clinical decisions to treat patients who have congestive heart failure with oral anticoagulants must be made on an individual basis.
CohnJNJohnsonGZiescheSCobbFRFrancisGTristaniF: A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med1991, 325: 303–310. See comment on the SOLVD study [2].
2.
The SOLVD Investigators: Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med1992, 327: 685–691. The results of Cohn et al. [1] and the SOLVD investigators indicate that many physicians do not routinely administer anticoagulation therapy to the majority of patients with advanced heart failure.
3.
FusterVGershBJGiulianiERTajikAJBrandenburgROFryeRL: The natural history of idiopathic dilated cardiomyopathy. Am J Cardiol1981, 47: 525–531. Although retrospective, this is an important study that is often quoted to justify recommendations for the administration of anticoagulation therapy to patients with heart failure.
4.
GottdienerJSGayJAVan VoorheesLDiBiancoRFletcherRO: Frequency and embolic potential of left ventricular thrombus in dilated cardiomyopathy: Assessment by 2-dimensional echocardiography. Am J Cardiol1983, 52: 1281–1285. See comment on Stratton et al. [6].
5.
HauglandJMAsingerRWMikellFLElspergerJHodgesM: Embolic potential of left ventricular thrombi detected by two-dimensional echocardiography. Circulation1984, 70: 588–598. See comment on Stratton et al. [6].
6.
StrattonJRNemanichJWJohannessenKAResnickAD: Fate of left ventricular thrombi in patients with remote myocardial infarction or idiopathic cardiomyopathy. Circulation1988, 78: 1388–1393. This study and those by Gottdiener et al. [4] and Haugland et al. [5] report a high incidence of thromboembolism in patients referred for echocardiographic studies.
7.
CiaccheriMCastelliGCecchiFNanniniMSantoroGTroianiV: Lack of correlation between intracavitary thrombosis detected by cross-sectional echocardiography and systemic emboli in patients with dilated cardiomyopathy. Br Heart J1989, 62: 26–29. The authors showed a low rate of thromboembolism in patients with left ventricular thrombus treated with warfarin.
8.
BlondheimDSJacobsLEKotlerMNCostacurtaGAParryWR: Dilated cardiomyopathy with mitral regurgitation: Decreased survival despite a low frequency of left ventricular thrombus. Am Heart J1991, 122: 763–771.
9.
FalkRHFosterECoatsMH: Ventricular thrombi and thromboembolism in dilated cardiomyopathy: A prospective follow-up study. Am Heart J1992, 123: 136–142. A small prospective trial in patients with idiopathic dilated cardiomyopathy.
10.
DunkmanWBJohnsonGRCarsonPEBhatGFarrellLCohnJN: Incidence of thromboembolic events in congestive heart failure. Circulation1993, 87 (suppl VI):VI94–VI101. This retrospective analysis from the Vasodilators in Heart Failure trials indicated a low risk of thromboembolism in a large study cohort.
11.
KatzSDMarantzPRBiasucciLJondeauGLeeKBrennanC: Low incidence of stroke in ambulatory patients with heart failure: A prospective study. Am Heart J1993, 126: 141–146. The largest prospective study of thromboembolism in heart failure. The incidence of stroke was less than two in 100 patient-years of follow-up.
12.
JohnsonRAPalaciosI: Dilated cardiomyopathies of the adult. N Engl J Med1982, 307: 1051–1058. See comment on Levine et al. [14].
13.
MeltzerRSVisserCAFusterV: Intracardiac thrombi and systemic embolization. Ann Intern Med1986, 104: 689–698. See comment on Levine et al. [14].
14.
LevineMNRaskobGHirschJ: Hemorrhagic complications of long-term anticoagulant therapy. Chest1989, 95 (suppl):25S–36S.
15.
AsingerRWMikellFLElspergerJHodgesM: Incidence of left-ventricular thrombosis after acute transmural myocardial infarction. N Engl J Med1981, 305: 297–302. See comment on Nihoyannopoulos et al. [17).
16.
LaPeyreACISteelePMKazimerFJChesebroJHVlietstraREFusterV: Systemic embolism in chronic left ventricular aneurysm: Incidence and the role of anticoagulation. J Am Coll Cardiol1985, 6: 534–538. See comment on Nihoyannopoulos et al. [17].
17.
NihoyannopoulosPSmithGCMaseriAFoaleRA: The natural history of left ventricular thrombus in myocardial infarction: A rationale in support of masterly inactivity. J Am Coll Cardiol1989, 14: 903–911. This study, along with those by Asinger et al. [15] and LaPeyre et al. [16], document a low incidence of thromboembolism in patients with myocardial infarcts of more than 6 months old.
18.
Van HoevenKHKitsisRNKatzSDFactorSM: Peripartum versus idiopathic dilated cardiomyopathy in young women: A comparison of clinical, pathologic, and prognostic features. Int J Cardiol1993, 40: 57–65. Peripartum cardiomyopathy may be associated with a greater than average risk of thromboembolism.
19.
RobertsWCFerransVJ: Pathologic anatomy of the cardiomyopathies. Idiopathic dilated and hypertrophic types, infiltrative types, and endomyocardial disease with and without eosinophilia. Hum Pathol1975, 6: 287–342. See comment on Reeder et al. [21].
20.
CabinHSRobertsWC: Left ventricular aneurysm, intraaneurysmal thrombus and systemic embolus in coronary heart disease. Chest1980, 77: 586–590. See comment on Reeder et al. [21].
21.
ReederGSLengyelMTajikAJSewardJBSmithHCDanielsonGK: Mural thrombus in left ventricular aneurysm. Incidence, role of angiography, and relation between anticoagulation and embolization. Mayo Clin Proc1981, 56: 77–81. These authors, as well as Roberts and Ferrans [19] and Cabin and Roberts [20], document that intracavitary thrombus is common in patients with dilated cardiomyopathy.
22.
MeltzerRSGuthanerDRakowskiHPoppRLMartinRP: Diagnosis of left ventricular thrombi by two-dimensional echocardiography. Br Heart J1979, 42: 261–265.
23.
TobinRSlutskyRAHigginsCB: Serial echocardiograms in patients with congestive cardiomyopathies: Lack of evidence of thrombus formation. Clin Cardiol1984, 7: 99–101. See comment on Keren et al. [26].
24.
VisserCAKanGMeltzerRSDunningAJRoelandtJ: Embolic potential of left ventricular thrombus after myocardial infarction: A two-dimensional echocardiographic study of 119 patients. J Am Coll Cardiol1985, 5: 1276–1280. See comment on Keren et al. [26].
25.
JugduttBISivaramCA: Prospective two-dimensional echocardiograpic evaluation of left ventricular thrombus and embolism after acute myocardial infarction. J Am Coll Cardiol1989, 13: 554–564. See comment on Keren et al. [26].
26.
KerenAGoldbergSGottliebSKleinJSchugerCMedinaA: Natural history of left ventricular thrombi: Their appearance and resolution in the post-hopitalization period of acute myocardial infarction. J Am Coll Cardiol1990, 15: 790–800. Tobin et al. [23], Visser et al. [24], Jugdutt and Sivaram [25] and Keren et al. document the natural history of left ventricular thrombus after myocardial infarction.
27.
LevineBKalmanJMayerLFillitHMPackerM: Elevated circulating levels of tumor necrosis factor in severe chronic heart failure. N Engl J Med1990, 323: 236–241. See comment on Ariad et al. [29].
28.
KatzSDRaoRBermanJWSchwarzMDemopoulosLBijouR: Pathophysiologic correlates of increased serum tumor necrosis factor in patients with congestive heart failure: Relation to nitric oxide-dependent vasodilation in the forearm circulation. Circulation1994, 90: 12–16. See comment on Ariad et al. [29].
29.
AriadSDvilanskyASobelRNathanI: Plasma von Willebrand factor levels and congestive heart failure. J Intern Med1991, 229:557. This study and those by Levine et al. [27] and Katz et al. [28] considered non-hemodynamic factors that may predispose patients with heart failure to intracavitary thrombosis.
30.
LechatPMasJLLascaultGLoronPTheartMKlimczacM: Prevalence of patent foramen ovale in patients with stroke. N Engl J Med1988, 318: 1148–1152. See comment on Kasper et al. [31].
31.
KasperWGeibelATiedeNJustH: Patent foramen ovale in patients with haemodynamically significant pulmonary embolism. Lancet1992, 340: 561–564. The authors, along with Lechat et al. [30], raise the question of whether systemic thromboembolism necessarily originates from the left side of the heart.
32.
PetersenPBoysenGGodtfredsenJAndersenEDAndersenB: Placebo-controlled, randomised trial of warfarin and aspirin for prevention of thromboembolic complications in chronic atrial fibrillation. Lancet1989, i:175–178. See comment on the SPAF study [33].
33.
Stroke Prevention in Atrial Fibrillation Study Group Investigators: Preliminary report of the Stroke Prevention in Atrial Fibrillation Study. N Engl J Med1990, 322: 863–868. This trial and that by Petersen et al. [32] are key studies documenting the efficacy of warfarin for reducing the risk of stroke in patients with chronic atrial fibrillation.
34.
KyrlePAKorningerCGossingerHGlogarDLechnerKNiessnerH: Prevention of arterial and pulmonary embolism by oral anticoagulants in patients with dilated cardiomyopathy. Thromb Haemost1985, 54: 521–523. An uncontrolled trial suggesting that warfarin may reduce the risk of thromboembolism in patients with congestive heart failure.
35.
TsevatJEckmanMHMcNuttRAPaukerSG: Warfarin for dilated cardiomyopathy. A bloody tough pill to swallow? Med Decis Making1989, 9: 162–169. A decision-analysis paper illustrating a useful tool for the analysis of difficult treatment decisions.
