Atrial fibrillation and thromboembolic risk in hypertrophic cardiomyopathy
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Atrial fibrillation (AF) is the most common sustained arrhythmia in patients with hypertrophic cardiomyopathy (HCM), conferring a markedly increased risk of thromboembolic events. Conventional risk stratification tools such as the CHA2DS2- VASc (congestive heart failure, hypertension, age ≥ 75 years [doubled], diabetes mellitus, prior stroke or transient ischemic attack [doubled], vascular disease, age 65–74 years, female sex) score are often insufficient to predict thromboembolic events in patients with HCM and AF, as thromboembolic risk in HCM is driven by diseasespecific structural, functional, and prothrombotic substrates. This review synthesizes current evidence on the epidemiology, pathophysiological mechanisms, and clinical impact of AF and thromboembolism in HCM. We discuss variable imaging modalities—including strain echocardiography, cardiac magnetic resonance, and cardiac computed tomography— that offer enhanced characterization of atrial remodeling and thromboembolic risk in patients with HCM. Furthermore, we outline current guideline-based anticoagulation strategies, the evolving role of direct oral anticoagulants, and adjunctive therapies such as left atrial appendage occlusion and catheter ablation. A comprehensive, multidisciplinary approach that incorporates advanced imaging, molecular profiling, and individualized management is ideal to optimize outcomes and reduce stroke burden in patients with HCM and AF.
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia in patients with hypertrophic cardiomyopathy (HCM), conferring a markedly increased risk of thromboembolic events. Conventional risk stratification tools such as the CHA2DS2- VASc (congestive heart failure, hypertension, age ≥ 75 years [doubled], diabetes mellitus, prior stroke or transient ischemic attack [doubled], vascular disease, age 65–74 years, female sex) score are often insufficient to predict thromboembolic events in patients with HCM and AF, as thromboembolic risk in HCM is driven by diseasespecific structural, functional, and prothrombotic substrates. This review synthesizes current evidence on the epidemiology, pathophysiological mechanisms, and clinical impact of AF and thromboembolism in HCM. We discuss variable imaging modalities—including strain echocardiography, cardiac magnetic resonance, and cardiac computed tomography— that offer enhanced characterization of atrial remodeling and thromboembolic risk in patients with HCM. Furthermore, we outline current guideline-based anticoagulation strategies, the evolving role of direct oral anticoagulants, and adjunctive therapies such as left atrial appendage occlusion and catheter ablation. A comprehensive, multidisciplinary approach that incorporates advanced imaging, molecular profiling, and individualized management is ideal to optimize outcomes and reduce stroke burden in patients with HCM and AF.