{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T15:44:38Z","timestamp":1791906278787,"version":"4.3.4"},"reference-count":42,"publisher":"Wiley","issue":"10","license":[{"start":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T00:00:00Z","timestamp":1791849600000},"content-version":"vor","delay-in-days":12,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T00:00:00Z","timestamp":1790812800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Echocardiography"],"published-print":{"date-parts":[[2026,10]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>Atrial fibrillation (AF) is the best\u2010established thromboembolic risk factor in rheumatic heart disease (RHD), but stroke and thromboembolism also occur without documented AF. We systematically synthesised associations between non\u2010AF clinical\/echocardiographic predictors and thromboembolism in RHD, comparing AF\u2010adjusted with unadjusted estimates.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>PubMed\/MEDLINE, Embase, Scopus, and Web of Science were searched, supplemented by Google Scholar and citation screening. Eligible studies evaluated RHD patients with \u22651 non\u2010AF predictor of stroke or thromboembolism. Two reviewers performed selection, extraction, and QUIPS risk\u2010of\u2010bias assessment; certainty was graded using GRADE. Unadjusted, adjusted, and AF\u2010adjusted estimates were extracted separately, and random\u2010effects meta\u2010analysis was performed when feasible.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Nineteen studies (\u223c8,206 patients) met eligibility criteria. SEC, LA size\/volume, LA\/appendage thrombus, LA appendage flow, LA mechanical function, mitral valve severity, age, and previous thromboembolism were most frequently examined. Four studies provided comparable crude ORs for SEC (pooled OR 8.27, 95% CI 3.21\u201321.29;\n                      <jats:italic>\n                        I\n                        <jats:sup>2<\/jats:sup>\n                      <\/jats:italic>\n                      = 66%), substantially attenuated after AF adjustment (as low as OR 1.7, 95% CI 1.1\u20133.0). Older age and previous stroke remained associated with thromboembolism in AF\u2010inclusive models, and LA mechanical\/reservoir function showed consistent inverse associations, including in sinus rhythm. Certainty was low for SEC, age, and LA function; moderate for previous stroke\/thromboembolism; very low for anticoagulation non\u2010use.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>In RHD, thromboembolic risk extends beyond documented AF. SEC showed the strongest unadjusted association but was substantially attenuated after AF adjustment, likely partly reflecting subclinical AF; it is TEE\u2010dependent and inconsistently graded. Older age, previous thromboembolism, and impaired LA mechanical\/reservoir function showed more persistent associations after AF\u2010inclusive adjustment; prospective validation is needed.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/echo.70649","type":"journal-article","created":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T14:46:06Z","timestamp":1791902766000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Beyond Atrial Fibrillation: Clinical and Echocardiographic Predictors of Ischaemic Stroke and Systemic Thromboembolism in Rheumatic Heart Disease: A Systematic Review and Meta\u2010Analysis"],"prefix":"10.1111","volume":"43","author":[{"given":"Naveen","family":"Baby","sequence":"first","affiliation":[{"name":"Department of Cardiology Jawaharlal Institute of Postgraduate Medical Education and Research  Puducherry India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nishanth","family":"Gowda","sequence":"additional","affiliation":[{"name":"Department of Neurology National Institute of Mental Health and Neurosciences  Bangalore Karnataka India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"H. V.","family":"Neha","sequence":"additional","affiliation":[{"name":"Department of Cardiology Jawaharlal Institute of Postgraduate Medical Education and Research  Puducherry India"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,10,13]]},"reference":[{"key":"e_1_2_14_2_1","unstructured":"WHO Expert Consultation on Rheumatic Fever and Rheumatic Heart Disease Rheumatic Fever and Rheumatic Heart Disease: Report of a WHO Expert Consultation Geneva 29 October \u2013 1 November 2001 World Health Organization WHO Technical Report Series No. 923 (2004)."},{"issue":"5","key":"e_1_2_14_3_1","doi-asserted-by":"crossref","first-page":"273","DOI":"10.1016\/j.hlc.2010.02.019","article-title":"Rheumatic Heart Disease in Indigenous Populations","volume":"19","author":"White H.","year":"2010","journal-title":"Heart, Lung & Circulation"},{"issue":"11","key":"e_1_2_14_4_1","doi-asserted-by":"crossref","first-page":"685","DOI":"10.1016\/S1473-3099(05)70267-X","article-title":"The Global Burden of Group a Streptococcal Diseases","volume":"5","author":"Carapetis J. R.","year":"2005","journal-title":"The Lancet Infectious Diseases"},{"key":"e_1_2_14_5_1","unstructured":"National Heart Foundation of Australia (RF\/RHD Guideline Development Working Group) Cardiac Society of Australia and New Zealand Diagnosis and Management of Acute Rheumatic Fever and Rheumatic Heart Disease in Australia \u2014 an Evidence\u2010based Review National Heart Foundation of Australia (2006)."},{"key":"e_1_2_14_6_1","doi-asserted-by":"crossref","DOI":"10.1016\/B978-012373960-5.00335-X","volume-title":"The Global Burden of Disease: 2004 update","author":"Mathers C.","year":"2008"},{"key":"e_1_2_14_7_1","doi-asserted-by":"crossref","first-page":"741","DOI":"10.7326\/0003-4819-52-4-741","article-title":"The Course of Mitral Stenosis Without Surgery: Ten and Twenty Year Perspectives","volume":"52","author":"Rowe J. C.","year":"1960","journal-title":"Annals of Internal Medicine"},{"key":"e_1_2_14_8_1","doi-asserted-by":"crossref","first-page":"878","DOI":"10.1161\/01.CIR.45.4.878","article-title":"Natural History of Mitral Stenosis: A Review","volume":"45","author":"Selzer A.","year":"1972","journal-title":"Circulation"},{"key":"e_1_2_14_9_1","doi-asserted-by":"crossref","first-page":"349","DOI":"10.1136\/hrt.24.3.349","article-title":"The Natural History of 271 Patients With Mitral Stenosis Under Medical Treatment","volume":"24","author":"Olesen K. H.","year":"1962","journal-title":"British Heart Journal"},{"key":"e_1_2_14_10_1","doi-asserted-by":"crossref","first-page":"530","DOI":"10.1136\/thx.23.5.530","article-title":"Incidence of Systemic Embolism Before and After Mitral Valvotomy","volume":"23","author":"Deverall P. 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J.","year":"1994","journal-title":"American Heart Journal"},{"issue":"18","key":"e_1_2_14_23_1","first-page":"1697","article-title":"Overestimation of Stroke Risk in Rheumatic Mitral Stenosis and the Implications for Oral Anticoagulation","volume":"142","author":"Karthikeyan G.","year":"2020","journal-title":"Circulation On My Mind Perspective"},{"issue":"3","key":"e_1_2_14_24_1","doi-asserted-by":"crossref","first-page":"722","DOI":"10.1016\/j.jstrokecerebrovasdis.2015.09.003","article-title":"Predicting the Outcomes of Acute Ischemic Stroke With Rheumatic Heart Disease: The Values of CHADS2, CHA2DS2\u2010VASc, and HAS\u2010BLED Scores","volume":"25","author":"Liu J.","year":"2016","journal-title":"Journal of Stroke and Cerebrovascular Diseases: The Official Journal of National Stroke Association"},{"key":"e_1_2_14_25_1","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1016\/j.ijcard.2006.11.128","article-title":"Percutaneous Balloon Commissurotomy Reduces Incidence of Ischemic Cerebral Stroke in Patients With Symptomatic Rheumatic Mitral Stenosis [letter]","volume":"123","author":"Liu T. 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P.","year":"2014","journal-title":"Journal of the American College of Cardiology Cardiovascular Imaging"},{"key":"e_1_2_14_27_1","doi-asserted-by":"crossref","first-page":"1456","DOI":"10.1161\/CIRCULATIONAHA.116.024769","article-title":"Clinical Outcomes in 3343 Children and Adults With Rheumatic Heart Disease From 14 Low\u2010 and Middle\u2010Income CounTries: Two\u2010Year Follow\u2010up of the Global Rheumatic Heart Disease Registry (the REMEDY study)","volume":"134","author":"Z\u00fchlke L.","year":"2016","journal-title":"Circulation"},{"key":"e_1_2_14_28_1","doi-asserted-by":"crossref","first-page":"2853","DOI":"10.1161\/STROKEAHA.112.670893","article-title":"Features of Acute Ischemic Stroke With Rheumatic Heart Disease in a Hospitalized Chinese Population","volume":"43","author":"Wang D.","year":"2012","journal-title":"Stroke; A Journal of Cerebral Circulation"},{"key":"e_1_2_14_29_1","doi-asserted-by":"crossref","first-page":"2695","DOI":"10.1161\/STROKEAHA.116.014512","article-title":"Rheumatic Mitral Valve Disease is Associated With Worse Outcomes in Stroke: A Thailand National Database Study","volume":"47","author":"Wood A. 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