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ISSN (Online): 1875-6557

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Review Article

The Dilemma in the Management of Patients with Heart Failure with Reduced Ejection Fraction, Sinus Rhythm and Left Ventricular Spontaneous Echo Contrast: A Narrative Review

Author(s): Hedieh Alimiorcid of author and Ali Tajik*

Volume 22, Issue 1, 2026

Published on: 27 May, 2025

Article ID: e1573403X363285 Pages: 10

DOI: 10.2174/011573403X363285250519064030

Price: $65

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Abstract

Heart failure (HF) is a complex clinical syndrome that arises from structural or functional impairment of ventricular filling or ejection of blood, resulting in previous characteristic symptoms of fatigue, dyspnea, and fluid retention. Among the complications of heart failure is the development of spontaneous echo contrast (SEC), characterized by a smoke-resembling appearance on echocardiograms, which indicates blood stasis in heart chambers. Despite being identified as an echocardiographic marker in the left atrium that correlates with thrombus formation and causes thromboembolic events, the clinical importance of left ventricular spontaneous echo contrast (LV-SEC) and the appropriate management for patients with this condition remain uncertain due to insufficient data. Anticoagulant therapy is generally recommended for patients with established left ventricular thrombus (LVT). However, for patients with heart failure with reduced ejection fraction (HFrEF) and sinus rhythm (SR), as a result of a decrease in thromboembolic events over time, it is typically not recommended. The main challenge lies in assessing the thromboembolic risk and determining appropriate management in patients with HFrEF, sinus rhythm (SR), and left ventricular spontaneous echo contrast (LV-SEC), compared to those with left ventricular thrombus (LVT) and those with HFrEF and SR without LV-SEC. The aim of this paper is to review the guidelines and trials on clinical characteristics, outcomes, and management of patients with LV-SEC and compare the suggested management with the established management for LVT and HF patients with sinus rhythm without LV-SEC.

Keywords: Left ventricular, heart failure, spontaneous echo contrast, thromboembolism, anticoagulation, sinus rhythm.

Graphical Abstract

Graphical abstract illustrating key findings of the study

[1]
Kemp CD, Conte JV. The pathophysiology of heart failure. Cardiovasc Pathol 2012; 21(5): 365-71.
[http://dx.doi.org/10.1016/j.carpath.2011.11.007] [PMID: 22227365]
[2]
Savarese G, Becher PM, Lund LH, Seferovic P, Rosano GMC, Coats AJS. Global burden of heart failure: A comprehensive and updated review of epidemiology. Cardiovasc Res 2023; 118(17): 3272-87.
[http://dx.doi.org/10.1093/cvr/cvac013] [PMID: 35150240]
[3]
Haseeb Ul Rasool M, Persand D, Salam S. The dilemma of use of anticoagulation in patients with heart failure with reduced ejection fraction and sinus rhythm: A case report and literature review. Cureus 2023; 15(2): e35211.
[http://dx.doi.org/10.7759/cureus.35211]
[4]
Kwaan HC, Sakurai S, Wang J. Rheological abnormalities and thromboembolic complications in heart disease: spontaneous echo contrast and red cell aggregation. Semin Thromb Hemost 2003; 29(5): 529-34.
[http://dx.doi.org/10.1055/s-2003-44559]
[5]
Liang D, Shi R, Zheng KI, Zhou X, Zhu Q, Chen M. Clinical characteristics and outcomes in patients with echocardiographic left ventricular spontaneous echo contrast. Int J Cardiol 2021; 330: 245-50.
[http://dx.doi.org/10.1016/j.ijcard.2021.02.005]
[6]
Taguchi Y, Takashima S, Hirai T, Fukuda N, Ohara K, Nakagawa K. Significant impairment of left atrial function in patients with cardioembolic stroke caused by paroxysmal atrial fibrillation. Intern Med 2010; 49(16): 1727-32.
[http://dx.doi.org/10.2169/internalmedicine.49.3580]
[7]
Ito T, Suwa M. Left atrial spontaneous echo contrast: relationship with clinical and echocardiographic parameters. Echo Res Pract 2019; 6(2): R65-73.
[http://dx.doi.org/10.1530/ERP-18-0083]
[8]
Uretsky S, Shah A, Bangalore S, et al. Assessment of left atrial appendage function with transthoracic tissue Doppler echocardiography. Eur J Echocardiogr 2009; 10(3): 363-71.
[http://dx.doi.org/10.1093/ejechocard/jen339] [PMID: 19193710]
[9]
Rastegar R, Harnick DJ, Weidemann P, et al. Spontaneous echo contrast videodensity isflow-related and is dependent on the relative concentrations of fibrinogen and red blood cells. J Am Coll Cardiol 2003; 41(4): 603-10.
[http://dx.doi.org/10.1016/S0735-1097(02)02898-X] [PMID: 12598072]
[10]
Sigel B, Coelho JCU, Schade SG, Justin J, Spigos DG. Effect of plasma proteins and temperature on echogenicity of blood. Invest Radiol 1982; 17(1): 29-33.
[http://dx.doi.org/10.1097/00004424-198201000-00005] [PMID: 7076431]
[11]
Merino A, Hauptman P, Badimon L, et al. Echocardiographic “smoke” is produced by an interaction of erythrocytes and plasma proteins modulated by shear forces. J Am Coll Cardiol 1992; 20(7): 1661-8.
[http://dx.doi.org/10.1016/0735-1097(92)90463-W] [PMID: 1452941]
[12]
Fatkin D, Loupas T, Low J, Feneley M. Inhibition of red cell aggregation prevents spontaneous echocardiographic contrast formation in human blood. Circulation 1997; 96(3): 889-96.
[http://dx.doi.org/10.1161/01.CIR.96.3.889] [PMID: 9264497]
[13]
Zotz RJ, Müller M, Genth-Zotz S, Darius H. Spontaneous echo contrast caused by platelet and leukocyte aggregates? Stroke 2001; 32(5): 1127-33.
[http://dx.doi.org/10.1161/01.STR.32.5.1127]
[14]
Sadanandan S, Sherrid MV. Clinical and echocardiographic characteristics of left atrial spontaneous echo contrast in sinus rhythm. J Am Coll Cardiol 2000; 35(7): 1932-8.
[http://dx.doi.org/10.1016/S0735-1097(00)00643-4]
[15]
Watanabe T, Shinoda Y, Ikeoka K, Inui H, Fukuoka H, Sunaga A. Dabigatran exhibits low intensity of left atrial spontaneous echo contrast in patients with nonvalvular atrial fibrillation as compared with warfarin. Heart Vessels 2017; 32(3): 326-32.
[http://dx.doi.org/10.1007/s00380-016-0871-5]
[16]
Fatkin D, Kelly RP, Feneley MP. Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast and thromboembolic risk in vivo. J Am Coll Cardiol 1994; 23(4): 961-9.
[http://dx.doi.org/10.1016/0735-1097(94)90644-0]
[17]
Mikell FL, Asinger RW, Elsperger KJ, Anderson WR, Hodges M. Regional stasis of blood in the dysfunctional left ventricle: echocardiographic detection and differentiation from early thrombosis. Circulation 1982; 66(4): 755-63.
[http://dx.doi.org/10.1161/01.CIR.66.4.755] [PMID: 7116593]
[18]
Lai HM, Aronow W, Rachdev A, Asija A, Lai KV, George J. Incidence of mortality in 1,040 patients with coronary heart disease or hypertensive heart disease with normal and abnormal left ventricular ejection fraction and with normal and abnormal QRS duration. Arch Med Sci 2008; 4(2): 140-2.
[19]
Mahajan N, Ganguly J, Simegn M, et al. Predictors of stroke in patients with severe systolic dysfunction in sinus rhythm: Role of echocardiography. Int J Cardiol 2010; 145(1): 87-9.
[http://dx.doi.org/10.1016/j.ijcard.2009.05.039] [PMID: 19520443]
[20]
Mele D, Soukhomovskaia O, Pacchioni E, et al. Improved detection of left ventricular thrombi and spontaneous echocontrast by tissue harmonic imaging in patients with myocardial infarction. J Am Soc Echocardiogr 2006; 19(11): 1373-81.
[http://dx.doi.org/10.1016/j.echo.2006.05.011] [PMID: 17098141]
[21]
Castello R, Pearson AC, Labovitz AJ. Prevalence and clinical implications of atrial spontaneous contrast in patients undergoing transesophageal echocardiography. Am J Cardiol 1990; 65(16): 1149-53.
[http://dx.doi.org/10.1016/0002-9149(90)90330-4] [PMID: 2330903]
[22]
Erbel R, Stern H, Ehrenthal W, et al. Detection of spontaneous echocardiographic contrast within the left atrium by transesophageal echocardiography: spontaneous echocardiographic contrast. Clin Cardiol 1986; 9(6): 245-52.
[http://dx.doi.org/10.1002/clc.4960090603] [PMID: 3720048]
[23]
Bilge M, Eryonucu B, Güler N, Akdemir İ, Aşker M. Transesophageal echocardiography assessment of left atrial appendage function in untreated systemic hypertensive patients in sinus rhythm. J Am Soc Echocardiogr 2000; 13(4): 271-6.
[http://dx.doi.org/10.1067/mje.2000.103959] [PMID: 10756244]
[24]
Handke M, Harloff A, Hetzel A, Olschewski M, Bode C, Geibel A. Predictors of left atrial spontaneous echocardiographic contrast or thrombus formation in stroke patients with sinus rhythm and reduced left ventricular function. Am J Cardiol 2005; 96(9): 1342-4.
[http://dx.doi.org/10.1016/j.amjcard.2005.06.085] [PMID: 16253611]
[25]
Cujec B, Polasek P, Voll C, Shuaib A. Transesophageal echocardiography in the detection of potential cardiac source of embolism in stroke patients. Stroke 1991; 22(6): 727-33.
[http://dx.doi.org/10.1161/01.STR.22.6.727] [PMID: 2057970]
[26]
Pearson AC, Labovitz AJ, Tatineni S, Gomez CR. Superiority of transesophageal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology. J Am Coll Cardiol 1991; 17(1): 66-72.
[http://dx.doi.org/10.1016/0735-1097(91)90705-E] [PMID: 1987242]
[27]
Black IW, Hopkins AP, Lee LC, Jacobson BM, Walsh WF. Role of transoesophageal echocardiography in evaluation of cardiogenic embolism. Heart 1991; 66(4): 302-7.
[http://dx.doi.org/10.1136/hrt.66.4.302] [PMID: 1747283]
[28]
Black IW. Spontaneous echo contrast: Where there’s smoke there’s fire. Echocardiography 2000; 17(4): 373-82.
[http://dx.doi.org/10.1111/j.1540-8175.2000.tb01153.x]
[29]
Bernhardt P, Schmidt H, Hammerstingl C, Lüderitz B, Omran H. Patients with atrial fibrillation and dense spontaneous echo contrast at high risk: A prospective and serial follow-up over 12 months with transesophageal echocardiography and cerebral magnetic resonance imaging. J Am Coll Cardiol 2005; 45(11): 1807-12.
[http://dx.doi.org/10.1016/j.jacc.2004.11.071]
[30]
Black IW, Hopkins AP, Lee LCL, Walsh WF. Left atrial spontaneous echo contrast: A clinical and echocardiographic analysis. J Am Coll Cardiol 1991; 18(2): 398-404.
[http://dx.doi.org/10.1016/0735-1097(91)90592-W] [PMID: 1856407]
[31]
Leung DY, Black IW, Cranney GB, Hopkins AP, Walsh WF. Prognostic implications of left atrial spontaneous echo contrast in nonvalvular atrial fibrillation. J Am Coll Cardiol 1994; 24(3): 755-62.
[http://dx.doi.org/10.1016/0735-1097(94)90025-6]
[32]
Lin WD, Xue YM, Liu FZ, Fang XH, Zhan XZ, Liao HT. Left atrial enlargement and non-paroxysmal atrial fibrillation as risk factors for left atrial thrombus/spontaneous Echo contrast in patients with atrial fibrillation and low CHA(2)DS(2)-VASc score. J Geriatr Cardiol 2020; 17(3): 155-9.
[http://dx.doi.org/10.11909/j.issn.1671-5411.2020.03.001]
[33]
Doud DN, Jacobs WR, Moran JF, Scanlon PJ. The natural history of left ventricular spontaneous contrast. J Am Soc Echocardiogr 1990; 3(6): 465-70.
[http://dx.doi.org/10.1016/S0894-7317(14)80362-3]
[34]
Unai S, Nguyen ML, Tanaka D, et al. Clinical significance of spontaneous echo contrast on extracorporeal membrane oxygenation. Ann Thorac Surg 2017; 103(3): 773-8.
[http://dx.doi.org/10.1016/j.athoracsur.2016.07.019] [PMID: 27692917]
[35]
Massussi M, Scotti A, Lip GYH, Proietti R. Left ventricular thrombosis: New perspectives on an old problem. Eur Heart J Cardiovasc Pharmacother 2021; 7(2): 158-67.
[http://dx.doi.org/10.1093/ehjcvp/pvaa066] [PMID: 32569361]
[36]
Bakalli A, Limani K, Leci-Tahiri L, Gjoka S, Pllana E. Acute lower limb ischemia as presenting symptom of acute myocardial infarction complicated with left ventricular thrombus in a young male patient: A case report. J Med Cases 2016; 7(5): 184-6.
[http://dx.doi.org/10.14740/jmc2480w]
[37]
Moss AJ, Shah ASV, Zuling ET, et al. Left ventricular thrombus after primary PCI for ST-elevation myocardial infarction: 1-year clinical outcomes. Am J Med 2019; 132(8): 964-9.
[http://dx.doi.org/10.1016/j.amjmed.2019.02.033] [PMID: 30871923]
[38]
Velangi PS, Choo C, Chen KHA, et al. Long-term embolic outcomes after detection of left ventricular thrombus by late gadolinium enhancement cardiovascular magnetic resonance imaging: A matched cohort study. Circ Cardiovasc Imaging 2019; 12(11): e009723.
[http://dx.doi.org/10.1161/CIRCIMAGING.119.009723] [PMID: 31707810]
[39]
Maniwa N, Fujino M, Nakai M, et al. Anticoagulation combined with antiplatelet therapy in patients with left ventricular thrombus after first acute myocardial infarction. Eur Heart J 2018; 39(3): 201-8.
[http://dx.doi.org/10.1093/eurheartj/ehx551] [PMID: 29029233]
[40]
Levine GN, McEvoy JW, Fang JC, et al. Management of patients at risk for and with left ventricular thrombus: A scientific statement from the American Heart Association. Circulation 2022; 146(15): e205-23.
[http://dx.doi.org/10.1161/CIR.0000000000001092] [PMID: 36106537]
[41]
Turgay Yildirim Ö, Akşit E, Aydin F, Hüseyinoğlu Aydin A. Efficacy of direct oral anticoagulants on left ventricular thrombus. Blood Coagul Fibrinolysis 2019; 30(3): 96-103.
[http://dx.doi.org/10.1097/MBC.0000000000000801] [PMID: 30864962]
[42]
Keita I, Aubin-Auger I, Lalanne C, et al. Assessment of quality of life, satisfaction with anticoagulation therapy, and adherence to treatment in patients receiving long-course vitamin K antagonists or direct oral anticoagulants for venous thromboembolism. Patient Prefer Adherence 2017; 11: 1625-34.
[http://dx.doi.org/10.2147/PPA.S131157] [PMID: 29026288]
[43]
Sonaglioni A, Nicolosi GL, Lombardo M, Anzà C, Ambrosio G. Prognostic relevance of left ventricular thrombus motility: Assessment by pulsed wave tissue doppler imaging. Angiology 2021; 72(4): 355-63.
[http://dx.doi.org/10.1177/0003319720974882]
[44]
Lip GY, Gibbs CR. Does heart failure confer a hypercoagulable state? Virchow’s triad revisited. J Am Coll Cardiol 1999; 33(5): 1424-6.
[http://dx.doi.org/10.1016/S0735-1097(99)00033-9]
[45]
Massie BM, Krol WF, Ammon SE, Armstrong PW, Cleland JG, Collins JF. The warfarin and antiplatelet therapy in heart failure trial (WATCH): Rationale, design, and baseline patient characteristics. J Card Fail 2004; 10(2): 101-12.
[http://dx.doi.org/10.1016/j.cardfail.2004.02.006]
[46]
Griffith GC, Stragnell R, Levinson DC, Moore FJ, Ware AG. A study of the beneficial effects of anticoagulant therapy in congestive heart failure. Ann Intern Med 1952; 37(5): 867-87.
[http://dx.doi.org/10.7326/0003-4819-37-5-867]
[47]
Pullicino P, Thompson JLP, Barton B, Levin B, Graham S, Freudenberger RS. Warfarin versus aspirin in patients with reduced cardiac ejection fraction (WARCEF): Rationale, objectives, and design. J Card Fail 2006; 12(1): 39-46.
[http://dx.doi.org/10.1016/j.cardfail.2005.07.007] [PMID: 16500579]
[48]
Cokkinos DV, Haralabopoulos GC, Kostis JB, Toutouzas PK. Efficacy of antithrombotic therapy in chronic heart failure: The HELAS study. Eur J Heart Fail 2006; 8(4): 428-32.
[http://dx.doi.org/10.1016/j.ejheart.2006.02.012] [PMID: 16737850]
[49]
Mehra MR, Vaduganathan M, Fu M, et al. A comprehensive analysis of the effects of rivaroxaban on stroke or transient ischaemic attack in patients with heart failure, coronary artery disease, and sinus rhythm: the COMMANDER HF trial. Eur Heart J 2019; 40(44): 3593-602.
[http://dx.doi.org/10.1093/eurheartj/ehz427] [PMID: 31461239]
[50]
Avellana P, Segovia J, Ferrero A, et al. Anticoagulation therapy in patients with heart failure due to systolic dysfunction and sinus rhythm: Analysis of REDINSCOR registry. Rev Esp Cardiol (Engl Ed) 2012; 65(8): 705-12.
[http://dx.doi.org/10.1016/j.rec.2011.11.016] [PMID: 22464104]
[51]
Alberts VP, Bos MJ, Koudstaal P, Hofman A, Witteman JC, Stricker B. Heart failure and the risk of stroke: The Rotterdam Study. Eur J Epidemiol 2010; 25(11): 807-12.
[http://dx.doi.org/10.1007/s10654-010-9520-y]
[52]
Kannel WB, Wolf PA, Verter J. Manifestations of coronary disease predisposing to stroke. The Framingham study. JAMA 1983; 250(21): 2942-6.
[http://dx.doi.org/10.1001/jama.1983.03340210040022] [PMID: 6227757]
[53]
Dries DL, Rosenberg YD, Waclawiw MA, Domanski MJ. Ejection fraction and risk of thromboembolic events in patients with systolic dysfunction and sinus rhythm: Evidence for gender differences in the studies of left ventricular dysfunction trials. J Am Coll Cardiol 1997; 29(5): 1074-80.
[http://dx.doi.org/10.1016/S0735-1097(97)00019-3] [PMID: 9120162]
[54]
Wolf PA, Kannel WB, McNamara PM. Occult impaired cardiac function, congestive heart failure, and risk of thrombotic stroke: The framingham study. Neurology 1970; 20(4): 373. [PMID: 5534972
[55]
Szummer KE, Solomon SD, Velazquez EJ, Kilaru R, McMurray J, Rouleau JL. Heart failure on admission and the risk of stroke following acute myocardial infarction: The VALIANT registry. Eur Heart J 2005; 26(20): 2114-9.
[http://dx.doi.org/10.1093/eurheartj/ehi352]
[56]
Petty GW, Brown RD Jr, Whisnant JP, Sicks JD, O’Fallon WM, Wiebers DO. Survival and recurrence after first cerebral infarction. Neurology 1998; 50(1): 208-16.
[http://dx.doi.org/10.1212/WNL.50.1.208] [PMID: 9443482]
[57]
Homma S, Thompson JL, Pullicino PM, Levin B, Freudenberger RS, Teerlink JR. Warfarin and aspirin in patients with heart failure and sinus rhythm. N Engl J Med 2012; 366(20): 1859-69.
[http://dx.doi.org/10.1056/NEJMoa1202299]
[58]
Zannad F, Anker SD, Byra WM, Cleland JGF, Fu M, Gheorghiade M. Rivaroxaban in patients with heart failure, sinus rhythm, and coronary disease. N Engl J Med 2018; 379(14): 1332-42.
[http://dx.doi.org/10.1056/NEJMoa1808848]
[59]
Lin AY, Dinatolo E, Metra M, et al. Thromboembolism in heart failure patients in sinus rhythm: Epidemiology, pathophysiology, clinical trials, and future direction. JACC Heart Fail 2021; 9(4): 243-53.
[http://dx.doi.org/10.1016/j.jchf.2021.01.009] [PMID: 33714744]
[60]
Miličić D, Samardžić J, Petričević M. Antithrombotics in heart failure. Croat Med J 2014; 55(6): 621-7.
[http://dx.doi.org/10.3325/cmj.2014.55.621] [PMID: 25559833]
[61]
De Belder MA, Lovat LB, Tourikis L, Leech G, Camm A. Left atrial spontaneous contrast echoes - markers of thromboembolic risk in patients with atrial fibrillation. Eur Heart J 1993; 14(3): 326-35.
[http://dx.doi.org/10.1093/eurheartj/14.3.326] [PMID: 8458351]
[62]
Han D, Chu Y, Wu Y, Wang X. Determinants of left atrial thrombus or spontaneous echo contrast in nonvalvular atrial fibrillation. Thromb Res 2020; 195: 233-7.
[http://dx.doi.org/10.1016/j.thromres.2020.07.055] [PMID: 32799130]
[63]
Backhaus JF, Pflaumbaum A, Krogias C, et al. Short- and long-term outcome of patients with spontaneous echo contrast or thrombus in the left atrial appendage in the era of the direct acting anticoagulants. Clin Res Cardiol 2021; 110(11): 1811-21.
[http://dx.doi.org/10.1007/s00392-021-01926-8] [PMID: 34436659]
[64]
Kreimer F, Backhaus JF, Krogias C, Pflaumbaum A, Mügge A, Gotzmann M. P‐wave parameters and their association with thrombi and spontaneous echo contrast in the left atrial appendage. Clin Cardiol 2023; 46(4): 397-406.
[http://dx.doi.org/10.1002/clc.23980] [PMID: 36808747]
[65]
Chen J, Zhou M, Wang H, et al. Risk factors for left atrial thrombus or spontaneous echo contrast in non-valvular atrial fibrillation patients with low CHA2DS2-VASc score. J Thromb Thrombolysis 2022; 53(2): 523-31.
[http://dx.doi.org/10.1007/s11239-021-02554-9] [PMID: 34476733]
[66]
Akamatsu K, Ito T, Ozeki M, Miyamura M, Sohmiya K, Hoshiga M. Left atrial spontaneous echo contrast occurring in patients with low CHADS2 or CHA2DS2-VASc scores. Cardiovasc Ultrasound 2020; 18(1): 31.
[http://dx.doi.org/10.1186/s12947-020-00213-2] [PMID: 31931808]
[67]
Wang H, Xi S, Chen J, Zhao L, Gan T, He B. Severe left atrial spontaneous echo contrast in nonvalvular atrial fibrillation: Clinical characteristics and impact on ischemic risk postablation. Thromb Haemost 2023; 123(5): 522-34.
[http://dx.doi.org/10.1055/a-1983-0516] [PMID: 36402133]
[68]
Yuan YW, Shung KK. Ultrasonic backscatter from flowing whole blood. I: Dependence on shear rate and hematocrit. J Acoust Soc Am 1988; 84(1): 52-8.
[http://dx.doi.org/10.1121/1.397238] [PMID: 3411055]
[69]
Heppell RM, Berkin KE, McLenachan JM, Davies JA. Haemostatic and haemodynamic abnormalities associated with left atrial thrombosis in non-rheumatic atrial fibrillation. Heart 1997; 77(5): 407-11.
[http://dx.doi.org/10.1136/hrt.77.5.407] [PMID: 9196408]
[70]
Zhou X, Shi R, Wu G, Zhu Q, Zhou C, Wang L. The prevalence, predictors, and outcomes of spontaneous echocardiographic contrast or left ventricular thrombus in patients with HFrEF. ESC Heart Fail 2021; 8(2): 1284-94.
[http://dx.doi.org/10.1002/ehf2.13196]
[71]
Vandvik PO, Lincoff AM, Gore JM, Gutterman DD, Sonnenberg FA, Alonso-Coello P. Primary and secondary prevention of cardiovasculardisease: Antithrombotic therapy and prevention of thrombosis,9th ed: American college of chest physicians evidence-based clinical practice guidelines. Chest . 2012; 141: pp. (2 Suppl)e637S--68s.
[http://dx.doi.org/10.1378/chest.11-2306]
[72]
O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: Executive summary: A report of the american college of cardiology foundation/american heart association task force on practice guidelines. Circulation 2013; 127(4): 529-55.
[http://dx.doi.org/10.1161/CIR.0b013e3182742c84]
[73]
Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The task force for the management of acute myocardial infarction in patients presenting with st-segment elevation of the european society of cardiology (ESC). Eur Heart J 2018; 39(2): 119-77.
[http://dx.doi.org/10.1093/eurheartj/ehx393]
[74]
Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D. 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline from the american heart association/american stroke association. Stroke 2021; 52(7): e364-467.
[http://dx.doi.org/10.1161/STR.0000000000000375]
[75]
Cleland JGF, Findlay I, Jafri S, et al. The warfarin/aspirin study in heart failure (WASH): A randomized trial comparing antithrombotic strategies for patients with heart failure. Am Heart J 2004; 148(1): 157-64.
[http://dx.doi.org/10.1016/j.ahj.2004.03.010] [PMID: 15215806]
[76]
Massie BM, Collins JF, Ammon SE, et al. Randomized trial of warfarin, aspirin, and clopidogrel in patients with chronic heart failure: The Warfarin and antiplatelet therapy in chronic heart failure (WATCH) trial. Circulation 2009; 119(12): 1616-24.
[http://dx.doi.org/10.1161/CIRCULATIONAHA.108.801753] [PMID: 19289640]
[77]
Nelson A. Prevalence of cardio-embolic event among patients with spontaneous echo contrast on transthoracic echocardiography (SMOCC-Heart Study). Philipp J Intern Med 2014; 52(2): 1-5.

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