The 2006 American Heart Association guidelines for management of patients with atrial fibrillation state: ''For patients with no identifiable thrombus in the left atrium (LA) or left atrial appendage (LAA), cardioversion (CV) is reasonable immediately after anticoagulation with unfractionated heparin. Thereafter, continuation of oral anticoagulation is reasonable for an anticoagulation period of at least 4 weeks.'' For patients with thrombus identified by transesophageal echocardiography, guidelines recommend therapeutic oral anticoagulation for 3 weeks prior to and 4 weeks after elective cardioversion.Patients with spontaneous echo contrast spontaneous echo contrast (SEC) identified by transesophageal echocardiogram (TEE) have a high risk of thromboembolic events, 1 -8 however, the guidelines do not address whether patients with SEC without thrombus can be safely cardioverted. This paper reviews the literature describing the pathogenesis of SEC, how it is detected, and whether elective cardioversion is safe.On the basis of our review, we believe that the risk of cardioembolic stroke after cardioversion of a patient with SEC is low, regardless of anticoagulation. The safe conclusion is that patients with SEC on TEE should receive therapeutic anticoagulation prior to cardioversion if possible and early cardioversion is not contraindicated.
Thrombotic thrombocytopenic purpura (TTP) rarely occurs in the setting of systemic lupus erythematosus (SLE); when it does occur it has a high mortality rate and is refractory to conventional treatment. No clear treatment guidelines exist when refractory TTP occurs in the setting of SLE. A 24-year-old male patient presented with TTP in the setting of SLE that was refractory to conventional treatment but responded to rituximab.
Greater parity between clinical trial and clinical practice can be achieved by selecting DHF patients in the context of a few general principles: trials should enroll patients on the basis of the diagnostic criteria set forth by the European Study Group on Diastolic Heart Failure. A history of (<6 months) or current hospitalization for heart failure along with prespecified higher grades of diastolic dysfunction insures that a sufficiently at-risk population is studied. Patients with DHF are older, with multiple noncardiovascular comorbidities, and longer trial duration (>3 years) may be plagued with competing risks.
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