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Cheating the CHA2DS2-VASc Score: Thromboembolism in Apical Hypertrophic Cardiomyopathy
Robin A P Weir1, Nicola MacKenzie1, Colin J Petrie2
1Cardiology Department, Hairmyres Hospital, East Kilbride, Glasgow G75 8RG, Scotland.
Insights
Atrial fibrillation increases stroke risk, but current scores like CHA2DS2-VASc may underestimate risk in hypertrophic cardiomyopathy. This condition warrants consideration for anticoagulation, even with low scores.
Area of Science:
- Cardiology
- Thrombosis
- Genetics
Background:
- Atrial fibrillation (AF) elevates systemic thromboembolism and stroke risk.
- Risk stratification scores (CHADS2, CHA2DS2-VASc) guide anticoagulation decisions.
- Certain conditions, like hypertrophic cardiomyopathy (HCM), pose risks not captured by current scores.
Purpose of the Study:
- To highlight the thromboembolic risk associated with apical hypertrophic cardiomyopathy (AHCM) in patients with atrial fibrillation.
- To suggest modifications to existing stroke risk scores to include cardiomyopathy-related risks.
Main Methods:
- Case report presentation.
- Review of existing risk stratification models for atrial fibrillation-related stroke.
- Clinical assessment of a patient with AHCM and AF.
Main Results:
- A patient with AHCM and AF experienced severe thromboembolic events despite a low CHA2DS2-VASc score.
- The CHA2DS2-VASc score did not accurately reflect the patient's thromboembolic risk.
Conclusions:
- Apical hypertrophic cardiomyopathy increases thromboembolic risk in atrial fibrillation patients.
- Current stroke risk scores may need revision to incorporate risks from specific cardiomyopathies.
- Consideration of anticoagulation in AF patients with AHCM is crucial, irrespective of standard risk scores.
Abstract:
Atrial fibrillation increases the risk of systemic thromboembolism in general and stroke in particular. Not all patients who develop atrial fibrillation are at significantly heightened risk of thromboembolic complications, however, with the development of risk scoring systems aiding clinicians in determining whether formal anticoagulation is mandated. The most commonly used contemporary scoring systems-CHADS2 and CHA2DS2-VASc-provide a reliable means of assessing stroke risk, but certain cardiac conditions are associated with an increased incidence of thromboembolism without impacting on these risk scores. Hypertrophic cardiomyopathy, with its apical variant, is such a condition. We present a case of a patient with apical hypertrophic cardiomyopathy and atrial fibrillation who suffered dire thromboembolic consequences despite a reassuringly low CHA2DS2-VASc score and suggest that this scoring system is modified to incorporate the thromboembolic risk inherent to certain cardiomyopathies irrespective of impairment of left ventricular systolic dysfunction or clinical heart failure.
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