Anticoagulation in cardiomyopathy: unravelling the hidden threat and challenging the threat individually

Abstract

Cardiomyopathy comprises a heterogeneous group of myocardial abnormalities, structural or functional in nature, in the absence of coronary artery disease and other abnormal loading conditions. These myocardial pathologies can result in premature death or disability from progressive heart failure, arrhythmia, stroke, or other embolic events. The European Cardiomyopathy Registry reports a high stroke risk in cardiomyopathy patients ranging from 2.1% to 4.5%, as well as high prevalence of atrial fibrillation ranging from 14.0% to 48.5%. There is a growing interest in evaluating the risk of thromboembolism depending on the type of cardiomyopathy, as well as if anticoagulation is indicated in patients with cardiomyopathy without atrial fibrillation. Data available do not unequivocally support anticoagulation therapy in all of these patients; the management of these patients remains challenging. Many published reports pertaining to the risk of thromboembolism and consecutive treatment strategies mainly focus on single cardiomyopathy subtype. We summarize essential pathophysiological knowledge and review current literature associated with thromboembolism in various cardiomyopathy subtypes, providing recommendations for the diagnostic evaluation as well as clinical management strategies in this field. Certain cardiomyopathy subtypes require anticoagulation independent of atrial fibrillation or CHA2DS2‐VASc score. Despite the scarcity of evidence regarding the choice of anticoagulation regimen (vitamin K antagonist vs. non‐vitamin K oral anticoagulants) in cardiomyopathy, it is discussed and reviewed in this article. Each patient should receive a tailored strategy based on thorough clinical evaluation, published evidence, and clinical experience, due to the current recommendations mostly developed on small‐sample studies or empirical evidence. The future research priorities in this area are also addressed in this article.

Multimodal Cardiac Imaging in the Assessment of Patients Who Have Suffered a Cardioembolic Stroke: A Review

“…Structural and functional abnormalities such as atrial dilatation, atrial standstill and AF in hypertrophic cardiomyopathy [135][136][137][138][139], a dilated and aneurysmic right ventricle in arrhythmogenic right-ventricular cardiomyopathy [140][141][142], and ventricular dilatation and dysfunction in dilated cardiomyopathy [134] also result in a hypercoagulable state. Other factors that contribute include systemic factors (e.g., systemic inflammation, catecholamine surge and endothelial injury in Takotsubo syndrome [132,133], eosinophilic infiltration in hypereosinophilic syndrome [143], and increased pro-coagulant activity in peripartum cardiomyopathy [144,145]) that drive the combination of platelet and tissue factor, thereby creating a hypercoagulable state [146]. TTE is the initial modality used to identify intracardiac thrombi, reduced ejection fraction, LV regional wall motion abnormalities, and dilated LA or LV, all of which are associated with an increased risk of stroke (Table 2) [147,148].…”

“…Dilated LA or LV in HF can result in blood flow stasis and left-atrial and aortic spontaneous echo contrast, with LA thrombus being best imaged via TOE and LV thrombus being best imaged via TTE [148,152]. As such, for patients with cardiomyopathy who have AF or who have suffered a cryptogenic stroke, it is strongly recommended that TOE is used to look for intracardiac thrombi and spontaneous echo contrast [146]. Three-dimensional echocardiography is more accurate than TTE, as the former can image the entire LV cavity geometry and requires fewer geometrical assumptions, though it remains dependent on good acoustic windows and operator skill [147].…”

“…CMR allows for the accurate assessment of LV ejection fraction as well as chamber dilation and is a class 1 recommendation for the diagnosis of HF in patients with suboptimal TTE imaging (Table 2) [147]. CMR can provide greater details regarding anatomy and the type of cardiomyopathy, providing the detail required for diagnosis [50,146,153,159]. Compared to echocardiography, CMR has higher sensitivity and specificity for the diagnosis of hypertrophic cardiomyopathy and is also able to detect myocardial fibrosis (which creates a pro-arrhythmic substrate) via delayed myocardial enhancement [50].…”