Prevalence and Predictors of Left Atrial Appendage Thrombus by Sex

Abstract

Background

Women with atrial fibrillation (AF) have historically been considered to have higher thromboembolic risk than men. The CHA₂DS₂-VASc score treated female sex as an independent risk factor. Recent guidelines recommend CHA₂DS₂-VA score, redefining female sex as a risk modifier.

Aims

This study aimed to assess the prevalence of left atrial appendage thrombus (LAAT) by sex and identify independent predictive factors for LAAT.

Methods

This analysis used data from the multicenter, prospective Left Atrial Thrombus on Transesophageal Echocardiography (LATTEE) registry, including 3,109 patients with AF. All patients underwent preprocedural transesophageal echocardiography to assess LAAT.

Results

Women constituted 36.5% of the study population. They were older, had more comorbidities, higher CHA₂DS₂-VA scores compared with men (median 3 vs. 2, p < 0.001). Among 3034 patients, LAAT was detected in 7.7% of cases, without significant difference between sexes (8% vs. 7.2%, p = 0.42). In multivariable logistic regression, paroxysmal AF was associated with lower odds of LAAT (OR 0.35), smoking (OR 1.71), reduced left ventricular ejection fraction (LVEF) <50% (OR 1.94), DOAC use (OR 0.42), and LAAV (per 1 cm/s increase; OR 0.92) were independent predictors of LAAT in men. In women only LAAV (per 1 cm/s increase; OR 0.91) remained significant (p < 0.001). No sex-related effect modification was observed (p > 0.05).

Conclusions

Although women with AF present a more adverse clinical profile, sex itself was not an independent predictor of LAAT.

Keywords

left atrial appendage thrombus thrombus predictive factors sex difference thromboembolic risk

Introduction

Atrial fibrillation (AF) is the most common supraventricular arrhythmia in clinical practice, affecting approximately 2-4% of the population.¹ To assess the risk of stroke in patients with AF, European guidelines have recommended the use of the CHA₂DS₂-VASc scoring system, which included female sex as one of the risk factors.² A higher risk of stroke in women than in men with AF has been evident in the historical trials on stroke prevention in AF.^3,4 However, observational study showed that women with no other risk factors (CHA2DS2-VASc score of 1) have a low stroke risk, similar to men with a CHA2DS2-VASc score of 0.⁵ In the presence of >1 non-sex stroke risk factor, women with AF consistently have significantly higher stroke risk than men.^6,7 There are still many doubts if female sex is an age-dependent risk modifier rather than a risk factor for stroke in AF.^8,9 In the latest 2024 European Society of Cardiology (ESC) guidelines for the management of AF, the approach to stroke risk assessment has been updated by removing female sex as an independent risk factor in the CHA₂DS₂-VA score.¹⁰

Despite this change, numerous studies suggest that women with more than one other risk factors for stroke remain at higher risk of thromboembolism than men.^6,7,11-13 There is debate as to whether female sex is an independent risk factor or merely modifies the effects of other factors.^7,14,15

The aim of this study was to analyze prevalence and predictive factors of left atrial appendage thrombus (LAAT) by sex. Although risk factors for thromboembolism in AF are well recognized, those strongly related to LAAT formation have not been precisely examined.

Materials and Methods

The analysis was carried out on patients from the Left Atrial Thrombus on Transesophageal Echocardiography (LATTEE) registry, which was a multicenter, prospective, observational study. Details of the LATTEE study methods have been presented in a previous article.¹⁶ Data were collected from patients (n=3109) who were admitted for ablation or cardioversion of AF/atrial flutter (AFl) at 13 Polish cardiology departments between November 2018 to May 2020. All patients underwent transesophageal echocardiography (TEE) before these procedures. As a result, all patients admitted for ablation and patients admitted for elective cardioversion who, according to the center’s practice, required confirmation of the effectiveness of antithrombotic treatment by TEE were included in the study. Exclusion criteria for our analysis were severe valvular heart disease including moderate/severe mitral stenosis or mechanical/biological mitral heart valve prosthesis.

Numerous data, including baseline demographic characteristics, AF type (diagnosed as pointed in the ESC guidelines²), concomitant diseases (with diagnostic criteria for heart failure (HF) as recommended in the European Society of Cardiology guidelines¹⁷), CHA₂DS₂-VA score calculation (according to the current guidelines¹⁰), laboratory and echocardiography test results, anticoagulation pharmacotherapy, were collected prospectively. Mandatory laboratory test involved complete blood cell counts, serum creatinine concentration with estimated glomerular filtration rate (eGFR) calculated from the Cockcroft-Gault formula, alanine and aspartate aminotransferases activity, international normalized ratio and activated partial thromboplastin time. Anticoagulation status (DOAC, VKA, or none) was recorded at admission for the procedure. Information on treatment duration, adherence, and DOAC dose (full vs reduced) was not collected systematically, and time in therapeutic range for VKA was unavailable.

Transthoracic (TTE) and transesophageal echocardiography examinations were performed according to a predefined protocol by experienced and certified echocardiographers. All echocardiographic parameters were calculated as recommended in the current guidelines of the European and American Societies of Cardiology.^18,19 During TEE, presence of thrombus in the left atrial appendage (LAA) and left atrial appendage emptying velocity (LAAV) were evaluated.

Ethics Approval Statement

The study was conducted according to good clinical practice guidelines and the Declaration of Helsinki and approved by the Ethics Committee of Medical University of Warsaw (AKBE/113/2018). The ethics committee waived the requirement for informed consent from patients, as all data were entered into the database anonymously and no additional tests or interventions were performed.

During the preparation of this work the authors declare to use Chat GPT only to create some of icons used in Graphical Abstract.

Statistical Analysis

All analyses were performed using Statistica 13.0 (StatSoft, Inc., Tulsa, OK, USA). Continuous variables are presented as mean ± standard deviation (SD) or median (interquartile range) depending on distribution; categorical variables are presented as counts and percentages. Normality was assessed using the Kolmogorov–Smirnov test. Between-sex comparisons used the independent t-test or Mann–Whitney U test for continuous variables and the chi-square test for categorical variables, as appropriate. A two-sided p-value < 0.05 was considered statistically significant.

Associations with LAAT were evaluated using logistic regression. Univariable models were fitted separately in women and men. Sex-stratified multivariable models were prespecified to include clinically relevant covariates selected a priori based on prior evidence and biological plausibility (AF type, smoking, LVEF category, anticoagulation status, and LAAV). In parallel, a global interaction model including sex and sex×predictor terms was fitted to test for effect modification; interaction p-values are reported from this model. Collinearity was assessed conceptually (overlapping constructs) and by correlation structure. When strong collinearity was present, only one representative variable was retained. Odds ratios (ORs) with 95% confidence intervals (CIs) are reported. Missing data were handled using complete-case analysis for each model (listwise deletion). In the sex-stratified multivariable models, the number of events was 80 in women (events-per-variable, EPV=16 for 5 predictors) and 155 in men (EPV=31), and sex-specific non-significance was interpreted in the context of precision and exposure frequency. LAAT was evaluated separately in men and women using ROC analysis (AUC with 95% CI). As an exploratory sensitivity analysis, a Youden-index–based LAAV cut-off was derived within each sex. Non-linearity of the LAAV–LAAT relationship was assessed using restricted cubic splines (likelihood-ratio test comparing spline vs linear term).

Results

Out of the 3034 patients included in the study, 1106 were women (36.5%). Figure 1 presents a flow chart of the population of our study.

Figure 1.

The flow chart of the study (AF – atrial fibrillation, AFl – atrial flutter)

Overall prevalence of LAAT was 7.7% (n=235). LAAT was slightly more frequently detected in men (n=155, 8%) compared to women (n=80, 7.2%), with no significant difference (p = 0.42).

Women were older, more frequently admitted for cardioversion, more often had the paroxysmal AF and more comorbidities, such as: hypertension, previous transient ischemic attack (TIA)/stroke and chronic kidney disease (CKD). The median CHA2DS2-VA score in women was significantly higher than in men. On the other hand, women less often presented with heart failure, were less often smokers (p < 0.001) and were more frequently treated with apixaban. Significant differences were also found in the laboratory and echocardiography parameters between the groups, as a lower left atrium area (LAa, p < 0.001), higher left ventricular ejection fraction (LVEF) (p < 0.001), and LAAV (per 1 cm/s increase) (p < 0.001). Detailed data are shown in Table 1.

Table 1.

Comparison of Baseline Characteristics Between Women and Men

Variables	n	Women n=1106 (36.5%)	n	Men n=1928 (63.5%)	p
The reason for admission, n (%)
Catheter ablation	1084	477 (44)	1907	971 (50.9)	<0.001
Cardioversion	1084	607 (56)	1907	936 (49.1)	<0.001
Type of AF/AFl
AF/AFl non-paroxysmal	1100	605 (55)	1923	1156 (60.1)	0.006
Time from AF/AFl diagnosis (years), median (IQR)	1005	2 (1-5)	1718	2 (1-5)	0.169
Demographic data
Age (years)	1104	70 (64-76)	1925	65 (56-71)	<0.001
BMI (kg/m²)	1027	29.4 (25.8-33.2)	1801	29.4 (26.5-32.7)	0.429
EHRA class	1105	2 (2-3)	1923	2 (2-3)	<0.001
		2.23 (0.81)		2 (2-3)
		2.23 (0.81)		2.12 (0.77)
Concomitant diseases, n (%)
Heart failure	1100	434 (39.5)	1924	851 (44.2)	0.011
HFrEF	1100	94 (8.6)	1924	366 (19.0)	<0.001
HFmrEF	1100	104 (9.5)	1924	245 (12.8)	0.006
HFpEF	1100	242 (22)	1924	244 (12.7)	<0.001
Hypertension	1106	892 (80.7)	1925	1426 (74.1)	<0.001
Diabetes mellitus	1106	267 (24.1)	1925	485 (25.2)	0.518
Previous TIA/Stroke	1106	128 (11.6)	1927	175 (9.1)	0.028
Coronary artery disease	1106	273 (24.7)	1925	596 (31)	<0.001
Chronic kidney disease	1106	202 (18.3)	1925	275 (14.3)	0.004
Smoking	1077	211 (19.6)	1834	779 (42.5)	<0.001
Malignant tumor	1106	39 (3.5)	1925	67 (3.5)	0.947
COPD	1106	34 (3.1)	1925	117 (6.1)	<0.001
CHA₂DS₂-VA score (points); median (IQR)	1093	3 (2-4)	1920	2 (1-4)	<0.001
Laboratory and echocardiography data, median (IQR)
Hemoglobin (g/dl)	1076	13.4 (12.4-14.4)	1853	14.6 (13.5-15.5)	<0.001
Creatinine (mg/dl)	1072	0.91 (0.8-1.1)	1856	1.05 (0.9-1.2)	<0.001
eGFR (mL/min/1.73 m²)	961	68.1 (54.1-86.1)	1687	89.9 (72.2-111.9)	<0.001
LVEF <50%, n (%)	899	209 (23.3)	1603	607 (37.9)	<0.001
LAd (mm)	879	44 (40-47)	1550	46 (42-50)	<0.001
LA area (cm²)	738	25 (21.1-28.6)	1267	27 (23-31)	<0.001
LAA emptying velocity (cm/s)	944	36 (25-50)	1637	40 (27-57)	<0.001
Oral anticoagulation therapy, n (%)
OAC therapy	1105	1000 (90.5)	1926	1727 (89.7)	0.464
VKA use	1105	172 (15.6)	1926	176 (14.3)	0.356
Warfarin	1105	79 (7.2)	1926	118 (6.1)	0.272
Acenocumarol	1105	93 (8.4)	1926	158 (8.2)	0.838
DOAC use	1105	828 (74.9)	1926	1451 (75.3)	0.804
Rivaroxaban	1105	377 (34.1)	1926	684 (35.5)	0.438
Dabigatran	1105	282 (25.5)	1926	534 (27.7)	0.188
Apixaban	1105	169 (15.3)	1926	233 (12.1)	0.013

Abbreviations: AF – atrial fibrillation, AFl – atrial flutter, BMI – Body Mass Index, CI – confidence interval, COPD – Chronic Obstructive Pulmonary Disease, DOAC – Direct Oral Anticoagulant, eGFR – estimated glomerular filtration rate, EHRA– European Heart Rhythm Association, HFmrEF – Heart Failure with mildly reduced Ejection Fraction, HFpEF – Heart Failure with preserved Ejection Fraction, HFrEF – Heart Failure with reduced Ejection Fraction, LAA – Left Atrial Appendage, LA area – Left Atrial area, LAd – Left Atrial diameter, LVEF – Left Ventricular Ejection Fraction, OAC – Oral Anticoagulation, TIA – Transient Ischemic Attack, VKA – Vitamin K Antagonist.

Comparative analysis showed the presence of many differences between groups with LAAT vs. those without LAAT, both in men and women. For the most part, the differences observed in men and women concerned the same parameters. Detailed results of these analyses are presented in Supplementary Tables S1 and S2.

In univariable logistic regression analysis for women, the predictors of LAA thrombus were as follows: paroxysmal AF associated with lower odds of LAAT (p < 0.001), older age (p < 0.001), heart failure (p < 0.001), diabetes mellitus (p = 0.04), LVEF <50% (p < 0.001), higher CHA2DS2-VA score (p < 0.001), higher LAd (p = 0.003), LAAV (per 1 cm/s increase) (p < 0.001) and less frequent direct oral anticoagulant (DOAC) use (p < 0.001) (Table 2).

Table 2.

Univariable Logistic Regression Analysis for Women and Men

	Men
	p-value	OR	95% CI
AF paroxysmal	<0.001	0.227	0.143-0.360
Age (per 1 year increase)	<0.001	1.035	1.020-1.051
Heart failure	<0.001	3.248	2.271-4.646
Diabetes mellitus	<0.001	1.985	1.408-2.798
Coronary artery disease	0.008	1.581	1.127-2.217
TIA/Stroke	<0.001	2.316	1.480-3.625
Chronic kidney disease	<0.001	2.501	1.709-3.660
Smoking	<0.001	2.175	1.535-3.082
CHA₂DS₂-VA (per 1 point increase)	<0.001	1.348	1.234-1.472
eGFR (per 1 mL/min/1.73 m² increase)	0.004	0.991	0.985-0.997
Hemoglobin (per 1 g/dl increase)	0.008	0.878	0.797-0.967
Creatinine (per 1 mg/dl increase)	0.009	1.422	1.092-1.853
LVEF <50%	<0.001	5.347	3.546-8.064
LAd (per 1 mm increase)	<0.001	1.064	1.034-1.094
LA area (per 1 cm² increase)	<0.001	1.045	1.021-1.069
LAAV, cm/s (per 1 cm/s increase)	<0.001	0.915	0.899-0.932
DOAC use	<0.001	0.361	0.258-0.505

	Women
	p-value	OR	95% CI
AF paroxysmal	<0.001	0.139	0.069-0.282
Age (per 1 year increase)	0.0006	1.044	1.019-1.070
Heart failure	<0.001	2.698	1.684-4.324
Diabetes mellitus	0.039	1.668	1.027-2.711
CHA₂DS₂-VA (per 1 point increase)	<0.001	1.299	1.142-1.478
LVEF <50%	<0.001	3.749	2.265-6.204
LAd (per 1 mm increase)	0.003	1.061	1.021-1.103
LAAV, cm/s (per 1 cm/s increase)	<0.001	0.892	0.863-0.921
DOAC use	<0.001	0.445	0.279-0.710

Abbreviations as in Table 1. OR – odds ratio, CI – confidence interval.

Univariable logistic regression analysis for men showed even more predictors of LAAT compared to women (Table 2).

In multivariable logistic regression, paroxysmal AF was associated with lower odds of LAAT, while smoking, reduced LVEF, DOAC use, and LAAV (per 1 cm/s increase) were identified as independent predictors of LAAT in men. In women, the direction of associations was comparable, with odds ratios of similar magnitude (e.g., smoking OR 1.22 vs. 1.71 in men; reduced LVEF OR 2.49 vs. 1.94). LAAV (per 1 cm/s increase) also emerged as a significant predictor in women, whereas the remaining associations did not reach statistical significance, likely reflecting the lower prevalence of risk factors and the limited number of events in this subgroup. Interaction analyses confirmed the absence of significant sex-related effect modification (all p for interaction > 0.05) (Table 3).

Table 3.

Multivariable Logistic Regression Analysis for Men and Women

	Multivariable analysisMen			Multivariable analysisWomen			Interaction analysis
	p-value	OR	95% CI	p-value	OR	95% CI	p
AF paroxysmal	0.012	0.35	0.15-0.79	0.1	0.26	0.05-1.29	0.695
Smoking	0.019	1.71	1.09-2.67	0.692	1.22	0.46-3.26	0.452
LVEF <50%	0.009	1.94	1.18-3.2	0.057	2.49	0.97-6.37	0.544
LAAV, cm/s (per 1 cm/s increase)	<0.001	0.92	0.9-0.94	<0.001	0.91	0.86-0.96	0.598
DOAC use	<0.001	0.42	0.27-0.65	0.193	0.55	0.23-1.35	0.47

Abbreviations as in Table 1. OR – odds ratio, CI – confidence interval.

P<0.05.

In sex-stratified ROC analyses, LAAV demonstrated good standalone discrimination for LAAT: AUC=0.818 (95% CI 0.780–0.855) in men and AUC=0.821 (95% CI 0.774–0.869) in women. The exploratory Youden-index cut-off was LAAV ≤30 cm/s in men (sensitivity 79.5%, specificity 70.3%) and ≤28 cm/s in women (sensitivity 80.6%, specificity 71.4%). Restricted cubic spline modelling suggested non-linearity of the LAAV–LAAT association in men (p = 0.00054) but not in women (p = 0.73). Therefore, in men the per-1 cm/s odds ratio for LAAV should be interpreted as an average (global) effect across the observed LAAV range rather than a strictly constant effect over the entire spectrum, while the inverse association between higher LAAV and lower odds of LAAT remained consistent.

A summary of the most important results is presented in Graphical Abstract (Figure 2).

Figure 2.

Graphical abstract (AF – atrial fibrillation, DOAC – Direct Oral Anticoagulant, LAAT – Left Atrial Appendage Thrombus, LAAV – Left Atrial Appendage Emptying Velocity, LVEF – Left Ventricular Ejection Fraction, OR – Odds Ratio)

Discussion

Our study provides new data on sex differences in the occurrence of LAAT in patients with AF. First, LAAT prevalence was numerically higher in men, but the between-sex difference was not statistically significant. Second, most candidate predictors showed broadly concordant directions of association across sexes. However, in multivariable models several covariates reached statistical significance only in men, while point estimates in women were generally similar but less precise. Only LAAV emerged as a statistically significant predictor of LAAT in both women and men. Finally, women and men differed in age, comorbidity burden, and echocardiographic and laboratory characteristics.

Previous studies have shown that women with AF are a population at higher risk of stroke than men, especially when other risk factors are present.^6,7,11-13 The mechanisms underlying this observation are not fully understood, but it is assumed that hormonal differences, structural changes in the atria and differences in the use and response to anticoagulation therapy may play an important role.^7,20

In our study, although women had significantly higher CHA₂DS₂-VA scores, the prevalence of LAAT was not higher than in men. This suggests that the risk of embolism in women may not be related to sex, but possibly the more frequent presence of co-existing risk factors.

Our results are consistent with studies questioning the role of female sex as an independent risk factor for stroke. In the ESC guidelines for the management of AF from 2024 the new CHA₂DS₂-VA score, which replaced the CHA₂DS₂-VASc, removes female sex as an independent risk factor for stroke, which is based on numerous studies and metaanalyses suggesting that women without other risk factors do not have a significantly higher thromboembolic risk than men.^10,13,21 In light of the current evidence, female sex should be viewed as a risk modifier rather than an independent risk factor.^6,11

In our study women were significantly older, had higher CHA₂DS₂-VA scores and were more likely to have comorbidities such as TIA/stroke and CKD. This is consistent with previous reports that women with AF have more comorbidities, which could potentially influence the thromboembolic risk.^21,22 Nevertheless, the prevalence of LAAT in women included in our analysis was not higher than in men, suggesting that clinical differences do not always directly translate into the risk of LAAT. The lack of interaction between sex and the analyzed predictors suggests that the mechanisms leading to left atrial appendage thrombus formation are generally similar in women and men. Furthermore, differences in cardiac structure and systolic function (e.g., smaller LAa and higher LVEF in women) may have a protective effect against thrombus formation.^20,23

The predictors of LAAT identified in the multivariable analysis remained statistically significant in men: paroxysmal AF associated with lower odds of LAAT, LVEF <50%, LAAV (per 1 cm/s increase), DOAC use, and smoking, which broadly confirms previous studies showing that these parameters are associated with atrial thrombosis risk.^12,24,25

In women, the direction of associations was similar, but only LAAV remained statistically significant, which may reflect the lower number of events and lower exposure frequency of several risk factors in this subgroup. Low LAAV is strongly associated with thrombus formation.²⁴ This highlights the need for detailed assessment of LAA function, particularly in patients with reduced LVEF and impaired LAA mechanical function.

Consistent with previous reports, a higher AF burden and longer arrhythmia duration promote atrial remodeling, reduce mechanical function, and create conditions for thrombus formation.²⁵ In our dataset, this concept was reflected by the observation that paroxysmal AF was associated with lower odds of LAAT.

In multivariable analysis, smoking and DOAC non-use were associated with higher odds of LAAT in men.^26,27 In women, smoking prevalence was lower and confidence intervals were wider. The direction of the association was similar, but statistical significance was not reached. Accordingly, these findings should be interpreted as reflecting differences in exposure frequency and precision rather than sex-specific biology.

Limitations of our study include its observational character and the possible influence of the selection of patients requiring TEE before planned procedures. However, the strength of the study results from the large multicenter cohort and standardization of echocardiographic examinations.²⁸ Because LATTEE is a procedure-based registry, the study population was restricted to patients who underwent pre-procedural TEE; cardioversion candidates underwent TEE according to center-level practice (routine vs selective TEE to confirm anticoagulation effectiveness). Denominator data on all AF admissions without TEE were not available, and we therefore cannot quantify centre-level TEE uptake or exclude selection bias that could influence observed LAAT prevalence or sex comparisons.

Conclusions

Our data suggest that although women with atrial fibrillation present a more adverse clinical profile, the prevalence of LAAT does not differ significantly from men, indicating that both sexes share similar risk for thrombus formation.

In multivariable analyses, LAAV (per 1 cm/s increase) emerged as an independent predictor of LAAT in both sexes. In men, additional independent predictors included paroxysmal AF (lower odds of LAAT), smoking, reduced left ventricular ejection fraction, and DOAC non-use. Although the set of statistically significant predictors differed by sex, the direction and strength of associations were broadly similar in women and men, with no evidence of a significant sex-related effect modification.These results emphasize the need for a comprehensive evaluation of patients referred for cardioversion or ablation, with particular attention paid to echocardiographic markers of LAA function and anticoagulation status.

Supplemental Material

Supplemental Material - Prevalence and Predictors of Left Atrial Appendage Thrombus by Sex

Supplemental Material for Prevalence and Predictors of Left Atrial Appendage Thrombus by Sex by Radosław Walczewski, Katarzyna Żelazowska-Chmielińska, Beata Uziębło-Życzkowska, Martyna Dąbrowska, Monika Gawałko, Monika Budnik, Konrad Pieszko, Katarzyna Starzyk, Beata Wożakowska-Kapłon, Damian Kaufmann, Ludmiła Daniłowicz-Szymanowicz, Maciej Wójcik, Robert Błaszczyk, Katarzyna Łojewska, Jarosław Hiczkiewicz, Maciej Wybraniec, Katarzyna Mizia-Stec, Katarzyna Kosmalska, Marcin Fijałkowski, Anna Szymańska, Joanna Syska-Sumińska, Maciej Haberka, Michał Kucio, Błażej Michalski, Karolina Kupczyńska, Anna Tomaszuk-Kazberuk, Katarzyna Wilk-Śledziewska, Renata Wachnicka-Truty, Marek Koziński, Paweł Burchardt, Paweł Krzesiński, Agnieszka Kapłon-Cieślicka in Clinical and Applied Thrombosis/Hemostasis.

Footnotes

ORCID iD

Katarzyna Żelazowska-Chmielińska

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article:LDS received honoraria for lectures from Bayer, Boehringer Ingelheim, and Pfizer outside the submitted work; other authors – none declared.

WHAT’S NEW?

The prevalence of left atrial appendage thrombus (LAAT) in patients with atrial fibrillation (AF) does not differ significantly between the sexes, despite more adverse clinical profile in women. Independent risk factors for LAAT are largely shared between the sexes. Although statistical significance in predicting LAAT was reached only in men, the direction of these associations was comparable in women. Only lower left atrial appendage emptying velocity emerged as a common predictive factor for both sexes. Interaction analyses confirmed the absence of significant sex-related effect modification.

Supplemental Material

Supplemental material for this article is available online.

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