Coronary Embolism in Atrial Fibrillation: A Distinct High-Risk Phenotype With Residual Thromboembolic Risk Despite Anticoagulation.

Figures

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  Figure 1. Study flowchart: patient selection and prevalence of CE*. AF indicates atrial fibrillation; AFL, atrial flutter; AMI, acute myocardial infarction; CABG, coronary artery bypass grafting; CE, coronary embolism; MI, myocardial infarction; and PCI, percutaneous coronary intervention. *Diagnostic criteria for CE: the Shibata criteria (see Table S1).

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  Figure 2. Representative angiographic features of CE. A, Distal vessel occlusion. B, The truncation sign. C, Spherical embolus. D, Multiple emboli. E and F, Systemic embolism imaging in the same patient. E, Coronary angiography revealed an embolism in the distal segment of posterior branches of the left ventricular artery. F, Computed tomography angiography of the mesenteric arteries demonstrated multiple emboli in the distal segment of the superior mesenteric artery. Arrows indicate the embolus location. CE indicates coronary embolism.

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  Figure 3. Long‐term risk of ischemic stroke: Kaplan–Meier and competing risk analyses. A, Kaplan–Meier curves showing the cumulative probability of ischemic stroke across the 3 study groups. Curves are adjusted for baseline covariates (age, sex, hypertension, diabetes, and left ventricular ejection fraction) using overlap weighting. B, Cumulative incidence function curves for ischemic stroke, accounting for the competing risk of nonstroke death (Fine‐Gray subdistribution model). Analyses are similarly adjusted via overlap weighting. Weighted numbers at risk (shown below the x axis) represent the sum of individual overlap weights for patients remaining under observation. This landmark analysis included 72 patients with AF‐related CE (CE with AF), 191 with non‐CE AMI with AF, and 3832 with non‐CE AMI without AF, all of whom survived the index hospitalization (in hospital or within 3 days). AF indicates atrial fibrillation; AMI, acute myocardial infarction; and CE, coronary embolism.

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  Figure 4. Clinical features and management framework of CE with concomitant AF. This schematic integrates key diagnostic features and proposes a management pathway. High‐risk markers include: female sex, structural heart disease, left atrial diameter ≥40 mm, and characteristic angiographic signs (distal embolization, truncation sign, and spherical thrombus). ACS indicates acute coronary syndrome; AF, atrial fibrillation; AMI, acute myocardial infarction; CAG, coronary angiography; CE, coronary embolism; DOAC, direct oral anticoagulant; IVUS, intravascular ultrasound; OCT, optical coherence tomography; PTCA, percutaneous transluminal coronary angioplasty; and TEE, transesophageal echocardiography.