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Silent cerebral infarcts in patients with atrial fibrillation: Clinical implications of an imaging-adjusted CHA2DS2-VASc score
, 2, 3, 2, 2, 3, 3, 3, 4, 4, 3, 2
Affiliations- Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
open access
Abstract
Background: The CHA2DS2-VASc score does not include silent infarcts on neuroimaging in stroke risk estimation for patients with atrial fibrillation (AF). The inclusion of silent infarcts into CHA2DS2-VASc scoring and its impact on stroke prophylaxis recommendations in patients with AF has not been previously studied. The present study sought to quantify the prevalence of silent infarcts in patients with AF and describe potential changes in management based on magnetic resonance imaging (MRI) findings.
Methods: Participants from the Mayo Clinic Study of Aging with AF and brain MRI were included. Silent infarcts were identified. “Standard” CHA2DS2-VASc scores were calculated for each subject based on clinical history alone and “imaging-adjusted” CHA2DS2-VASc scores based on evidence of cerebral infarction on MRI. Standard and imaging-adjusted scores were compared.
Results: One hundred and forty-seven participants (average age 77, 28% female) were identified with AF, MRI, and no clinical history of stroke. Overall, 41 (28%) patients had silent infarcts on MRI, corresponding with a 2-point increase in CHA2DS2-VASc score. Of these participants, only 39% (16/41) with silent infarct were on anticoagulation despite having standard CHA2DS2-VASc scores supportive of anticoagulation. After incorporating silent infarcts, 13% (19/147) would have an indication for periprocedural bridging compared to 0.6% (1/147) at baseline.
Conclusions: Incorporation of silent infarcts into the CHA2DS2-VASc score may change the risk- -benefit ratio of anticoagulation. It may also increase the number of patients who would benefit from periprocedural bridging. Future research should examine whether an anticoagulation strategy based on imaging-adjusted CHA2DS2-VASc scores could result in a greater reduction of stroke and cognitive decline.
Abstract
Background: The CHA2DS2-VASc score does not include silent infarcts on neuroimaging in stroke risk estimation for patients with atrial fibrillation (AF). The inclusion of silent infarcts into CHA2DS2-VASc scoring and its impact on stroke prophylaxis recommendations in patients with AF has not been previously studied. The present study sought to quantify the prevalence of silent infarcts in patients with AF and describe potential changes in management based on magnetic resonance imaging (MRI) findings.
Methods: Participants from the Mayo Clinic Study of Aging with AF and brain MRI were included. Silent infarcts were identified. “Standard” CHA2DS2-VASc scores were calculated for each subject based on clinical history alone and “imaging-adjusted” CHA2DS2-VASc scores based on evidence of cerebral infarction on MRI. Standard and imaging-adjusted scores were compared.
Results: One hundred and forty-seven participants (average age 77, 28% female) were identified with AF, MRI, and no clinical history of stroke. Overall, 41 (28%) patients had silent infarcts on MRI, corresponding with a 2-point increase in CHA2DS2-VASc score. Of these participants, only 39% (16/41) with silent infarct were on anticoagulation despite having standard CHA2DS2-VASc scores supportive of anticoagulation. After incorporating silent infarcts, 13% (19/147) would have an indication for periprocedural bridging compared to 0.6% (1/147) at baseline.
Conclusions: Incorporation of silent infarcts into the CHA2DS2-VASc score may change the risk- -benefit ratio of anticoagulation. It may also increase the number of patients who would benefit from periprocedural bridging. Future research should examine whether an anticoagulation strategy based on imaging-adjusted CHA2DS2-VASc scores could result in a greater reduction of stroke and cognitive decline.
Keywords
anticoagulation, atrial fibrillation, bridging, magnetic resonance imaging, silent infarct
About this articleTitle
Silent cerebral infarcts in patients with atrial fibrillation: Clinical implications of an imaging-adjusted CHA2DS2-VASc score
Journal
Issue
Article type
Original Article
Pages
766-772
Published online
2022-06-09
Page views
4663
Article views/downloads
619
DOI
Pubmed
Bibliographic record
Cardiol J 2022;29(5):766-772.
Keywords
anticoagulation
atrial fibrillation
bridging
magnetic resonance imaging
silent infarct
Authors
John P. Bretzman
Andrew S. Tseng
Jonathan Graff-Radford
Hon-Chi Lee
Samuel J. Asirvatham
Michelle M. Mielke
David S. Knopman
Ronald C. Petersen
Clifford R. Jack Jr.
Prashanthi Vemuri
Alejandro A. Rabinstein
Christopher V. DeSimone
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