P3706Atrial fibrillation with CHA2DS2-VASC =0. Really no need for anticoagulation?

• Published in: European heart journal Vol. 40; no. Supplement_1
• Main Authors: Cosmi, D, Mariottoni, B, Cosmi, F
• Format: Journal Article
• Language: English
• Published: Oxford University Press 01-10-2019
• Subjects: Stroke: Cardiogenic Embolism
• ISSN: 0195-668X; 1522-9645
• DOI: 10.1093/eurheartj/ehz745.0560

Abstract
Background
Based on the ESC guidelines on Atrial Fibrillation, oral anticoagulation is recommended in male patients with CHA2DS2-VASC score ≥1, in females if CHA2DS2-VASC is ≥2. In our research, we evaluated if there are patients at risk of significant thromboembolic events among those whose CHA2DS2-VASC score is apparently = 0, that could benefit of anticoagulant therapy.
Methods
Over the last 12 years, 20,154 outpatients were evaluated in our clinics. We found the presence of non valvular atrial fibrillation in 3.043 (15.1%) patients. In 176 (5.7%) of them the CHA2DS2-VASC was = 0. None of them, as suggested in the guidelines, received oral anticoagulants or antiplatelet drugs. In these patients, we evaluated the presence of other two important cardiovascular risk factors, not included in CHA2DS2-VASC score: cigarette smoking and hypercholesterolemia.
Results
Smoking patients were 70, of whom heavy smokers (≥20 cigarettes/day) were 32. Patients with LDL cholesterol>115 mg/dl were 55. During one year follow-up, 3 of 176 patients (1.7%) with CHA2DS2-VASC score = 0 had a stroke. These patients were all heavy smokers and one of them also had high LDL values; they didn't show significant carotid stenosis or carotid dissection. None of the patients was found to have thrombophilic disorders.
Transthoracic echocardiogram was performed, resulting negative for patent foramen ovale, ventricular dysfunction, or masses.
All patients underwent 24 hours blood pressure monitoring, and it was found that all of them had masked hypertension; lower extremity arterial evaluation revealed mild, asymptomatic peripheral arterial disease, with ABI <0.9. No events occurred in patients with elevated LDL, not heavy smokers.
The risk of stroke in the population of heavy smokers, even if CHA2DS2-VASC score was apparently = 0, was 9.3%, with a clear indication for anticoagulation.
Conclusions
In heavy smokers patients with atrial fibrillation, CHA2DS2-VASC score could apparently be =0, when they are only clinically evaluated. In fact, these patients often have asymptomatic peripheral arterial disease of the lower limbs and masked hypertension.
Our research highlights how in some subgroups of patients there could be some “hidden” risk factors, that we should keep in mind and closely search for when evaluating the risk of cardioembolic stroke, that remains high.