Echocardiography. 2018;35:817–826. wileyonlinelibrary.com/journal/echo
© 2018 Wiley Periodicals, Inc.
Evaluation of sex differences in the relationship between
diastolic dysfunction and thromboembolism using propensity
Mi-Na Kim MD, PhD | Jae-Min Shim MD, PhD | Jong-il Choi MD, PhD |
Seong-Mi Park MD, PhD | Young Hoon Kim MD, PhD | Wan Joo Shim MD, PhD
1 | BACKGROUND
Several epidemiologic studies have demonstrated a higher throm-
boembolic risk in women with atrial fibrillation (AF) than in men.
Clinical studies have also suggested that the addition of female sex
to the risk stratification model of the CHADS2 score resulting in the
CHA2DS2- VASc score improved the accuracy of thromboembolic
The reasons for increased thrombogenicity in women have
been considered to be multifactorial. Underuse of anticoagulation,
Division of Cardiology, Korea University
Anam Hospital, Seoul, Korea
Wan-Joo Shim, Korea University
Cardiovascular Center, Korea University
Anam Hospital, Seoul, Korea.
Background: Female sex is a risk factor for thromboembolism (TE) in atrial fibrillation
(AF); however, the underlying mechanisms are unclear. We postulated that left ven-
tricular (LV) diastolic dysfunction (LVDD) could be associated with increased throm-
boembolic risk in women.
Methods: From a retrospective cohort, 158 patients (female : male = 79:79) with
nonvalvular AF were propensity score- matched for age, presence of diabetes, hyper-
tension, coronary artery disease, congestive heart failure, embolic history, AF type,
and AF duration. Cardiac size and function and central aortic stiffness parameters
were evaluated. Diastolic function was classified as normal, indeterminate, and LVDD
according to recent guidelines. Surrogate markers for thromboembolism (dense
spontaneous echo contrast and thrombus) were evaluated using transesophageal
Results: Surrogate markers for TE showed a trend to be more frequent in women
than in men (21.5% vs 11.4%, P = .086). LVDD was more prevalent in women than in
men (22.8% vs 2.5%, P < .001); however, the prevalence of indeterminate diastolic
function was not different between sexes (26.6% vs 20.3%, P = .453). Surrogate
markers for TE were detected mostly in women with LVDD. LV diastolic parameters
showed a restrictive pattern, and aortic stiffness parameters were worse in women
than in men. Women with LVDD had increased aortic stiffness compared to women
with indeterminate and normal function, whereas aortic stiffness did not differ
among men in all groups. Significant relations between LV diastolic function and aor-
tic stiffness parameters were observed only in women.
Conclusion: LVDD due to increased aortic stiffness could be related to a higher
thromboembolic risk in women with AF.
atrial fibrillation, diastolic dysfunction, embolism, sex difference