Predictors of Systemic Embolism in Patients with Mitral Stenosis: A Prospective Study

  1. Cheng-Wen Chiang, MD;
  2. Sing-Kai Lo, PhD;
  3. Yu-Shien Ko, MD;
  4. Nye-Jan Cheng, MD;
  5. Pyng Jing Lin, MD; and
  6. Chau-Hsiung Chang, MD
  1. For author affiliations and current author addresses, see end of text. Grant Support: In part by grants NSC 81-0412-B182-15 and NSC 82-0412-B182-023 from the National Science Council, Taiwan, Republic of China, and grant CMRP420 from Chang Gung Memorial Hospital, Taipei, Taiwan, Republic of China. Requests for Reprints: Cheng-Wen Chiang, MD, The First Cardiovascular Division, Chang Gung Memorial Hospital, 199 Tung Hwa North Road, Taipei, 105, Taiwan, Republic of China. Current Author Addresses: Drs. Chiang, Ko, Cheng, Lin, and Chang: Chang Gung Memorial Hospital, 199 Tung Hwa North Road, Taipei, 105, Taiwan, Republic of China.

    Abstract

    Background: Most studies of the predictors of systemic embolism in patients with mitral stenosis have been retrospective.

    Objective: To prospectively study factors associated with systemic embolism in mitral stenosis.

    Design: Prospective cohort study.

    Setting: University-affiliated medical institution with 3000 beds.

    Patients: 534 consecutive patients with a mitral valve area of 2.0 cm (2) or less; 132 patients were in sinus rhythm, and 402 were in atrial fibrillation.

    Measurements: Nine clinical and 10 echocardiographic variables were assessed for prediction of systemic embolism over a mean (±SD) follow-up of 36.9 ± 22.5 months. Diagnosis of systemic embolism was based on symptoms and signs (sudden onset of peripheral arterial ischemic or neurologic manifestations without prodromes) and on findings on computed tomography, angiography, and surgery.

    Results: For patients in sinus rhythm, age (relative risk [RR], 1.12 [95% CI, 1.04 to 1.21]), the presence of a left atrial thrombus (RR, 37.1 [CI, 2.82 to 487.8]), mitral valve area (RR, 16.9 [CI, 1.53 to 187.0]), and the presence of significant aortic regurgitation (RR, 22.4 [CI, 2.72 to 184.8]) were positively associated with embolism. For patients in atrial fibrillation, previous embolism (RR, 3.11 [CI, 1.66 to 5.85]) was positively associated with embolism; percutaneous balloon mitral commissurotomy (RR, 0.37 [CI, 0.18 to 0.79]) was a negative predictor.

    Conclusions: It may be prudent to give anticoagulants not only to patients in atrial fibrillation and patients with previous systemic embolism but also to those showing a left atrial thrombus or significant aortic regurgitation on echocardiography. Early percutaneous balloon mitral commissurotomy may also help prevent systemic embolism in patients with mitral stenosis.

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    1. Ann Intern Med June 1, 1998 vol. 128 no. 11 885-889
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