Vitamin K Antagonist in Hypertrophic Cardiomyopathy and AF
Hypertrophic cardiomyopathy (HCM), which was first described in 1958, occurs in approximately one in 500 people. Patients with HCM are at an increased risk of atrial fibrillation, which is not only poorly tolerated in this population, but also increases their risk of an embolic event. The incidence of stroke in HCM patients with atrial fibrillation is approximately 21–23%. Given the high risk of stroke, antithrombotic therapy with warfarin is recommended in national guidelines. This therapy should be used without regard to other risk factors for stroke that may be present. Anticoagulation with the new oral anticoagulants may be considered as an alternative; although, specific data for patients with HCM is not available. The purpose of this review is to remind practitioners of the importance of stroke prophylaxis with oral anticoagulants in this population.
Atrial fibrillation (AF) is a commonly reported complication of hypertrophic cardiomyopathy (HCM) and is considered the most frequently encountered supraventricular arrhythmia in patients with HCM. It can be paroxysmal or chronic and can occur with or without left ventricular outflow tract obstruction. Patients with HCM do not tolerate AF well due to loss of the 'atrial kick'. This requires aggressive management of controlling symptoms (rate and/or rhythm control strategy), as well as long term anticoagulation to decrease the risk of thromboembolic events found to be higher in such patients. Despite guideline recommendations that advocate for an aggressive approach of anticoagulation in patients with HCM and AF, regardless of cardiac failure, hypertension, age, diabetes, stroke (doubled) (CHADS2)/cardiac failure or dysfunction, hypertension, age 75 years (doubled), diabetes, stroke (doubled)-vascular disease, age 65–74, sex category (female) (CHA2DS2-VASc) score, this therapy is often neglected. The purpose of this paper is to review the literature surrounding stroke risk in the HCM population with AF and highlight the importance of stroke prophylaxis with warfarin regardless of other risk factors.
Abstract and Introduction
Abstract
Hypertrophic cardiomyopathy (HCM), which was first described in 1958, occurs in approximately one in 500 people. Patients with HCM are at an increased risk of atrial fibrillation, which is not only poorly tolerated in this population, but also increases their risk of an embolic event. The incidence of stroke in HCM patients with atrial fibrillation is approximately 21–23%. Given the high risk of stroke, antithrombotic therapy with warfarin is recommended in national guidelines. This therapy should be used without regard to other risk factors for stroke that may be present. Anticoagulation with the new oral anticoagulants may be considered as an alternative; although, specific data for patients with HCM is not available. The purpose of this review is to remind practitioners of the importance of stroke prophylaxis with oral anticoagulants in this population.
Introduction
Atrial fibrillation (AF) is a commonly reported complication of hypertrophic cardiomyopathy (HCM) and is considered the most frequently encountered supraventricular arrhythmia in patients with HCM. It can be paroxysmal or chronic and can occur with or without left ventricular outflow tract obstruction. Patients with HCM do not tolerate AF well due to loss of the 'atrial kick'. This requires aggressive management of controlling symptoms (rate and/or rhythm control strategy), as well as long term anticoagulation to decrease the risk of thromboembolic events found to be higher in such patients. Despite guideline recommendations that advocate for an aggressive approach of anticoagulation in patients with HCM and AF, regardless of cardiac failure, hypertension, age, diabetes, stroke (doubled) (CHADS2)/cardiac failure or dysfunction, hypertension, age 75 years (doubled), diabetes, stroke (doubled)-vascular disease, age 65–74, sex category (female) (CHA2DS2-VASc) score, this therapy is often neglected. The purpose of this paper is to review the literature surrounding stroke risk in the HCM population with AF and highlight the importance of stroke prophylaxis with warfarin regardless of other risk factors.
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