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. 2022;29(5):766-772.
doi: 10.5603/CJ.a2022.0055. Epub 2022 Jun 15.

Silent cerebral infarcts in patients with atrial fibrillation: Clinical implications of an imaging-adjusted CHA2DS2-VASc score

John P Bretzman  1 , Andrew S Tseng  2 , Jonathan Graff-Radford  3 , Hon-Chi Lee  2 , Samuel J Asirvatham  2 , Michelle M Mielke  3 , David S Knopman  3 , Ronald C Petersen  3 , Clifford R Jack Jr  4 , Prashanthi Vemuri  4 , Alejandro A Rabinstein  3 , Christopher V DeSimone  5
Affiliations

Silent cerebral infarcts in patients with atrial fibrillation: Clinical implications of an imaging-adjusted CHA2DS2-VASc score

John P Bretzman et al. Cardiol J. 2022.

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.

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Conflict of interest statement

Conflict of interest: Michelle M. Mielke has consulted for Biogen and Brain Protection Company. David S. Knopman serves on a Data Safety Monitoring Board for the DIAN study. He serves on a Data Safety monitoring Board for a tau therapeutic for Biogen but receives no personal compensation. He is an investigator in clinical trials sponsored by Biogen, Lilly Pharmaceuticals and the University of Southern California. He has served as a consultant for Roche, Samus Therapeutics, Third Rock and Alzeca Biosciences but receives no personal compensation. He receives funding from the NIH. Clifford R. Jack Jr. serves on an independent data monitoring board for Roche, has served as a speaker for Eisai, and consulted for Biogen, but he receives no personal compensation from any commercial entity. He receives research support from NIH, the GHR Foundation and the Alexander Family Alzheimer’s Disease Research Professorship of the Mayo Clinic. Prashanthi Vemuri is funded by NIH and received speaking fees from Miller Medical Communications Inc. The remaining authors have nothing to disclose.

Figures

Figure 1
Figure 1
Study design and summary of results. 147 participants with atrial fibrillation, magnetic resonance imaging upon enrollment, and no clinical history of stroke were identified. 41/147 had silent infarct. Notably, only 39% were anticoagulated despite all having an indication for anticoagulation; AC — anticoagulation; ASA — acetylsalicylic acid; DAPT — dual antiplatelet therapy.
Figure 2
Figure 2
Change from standard to image adjusted CHA2DS2-VASc score. After incorporating imaging evidence of silent infarct, many participants had an increase in CHA2DS2-VASc score, causing a shift to the right.
Figure 3
Figure 3
The present study found that the prevalence of silent infarct in patients with atrial fibrillation is 28%. 39% of these participants were anticoagulated, despite all of them having an indication for anticoagulation. After incorporating silent infarct into stroke risk estimation, 44% of those with silent stroke had a new indication for periprocedural bridging. The top of the figure shows how CHA2DS2-VASc scores change after imaging adjustment.
See this image and copyright information in PMC

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