Future Perspectives to Improve CHA2DS2VASc Score: The Role of Left Atrium Remodelling, Inflammation and Genetics in Anticoagulation of Atrial Fibrillation

Abstract

In 10% of ischemic strokes, non-valvular atrial fibrillation (NVAF) is detected retroactively. Milder, or even asymptomatic forms of NVAF have shown high mortality, thrombotic risk, and deterioration of cognitive function. The current guidelines for the diagnosis and treatment of AF contain "grey areas", such as the one related to anticoagulant treatment in men with CHA2DS2-VASc score 1 and women with score 2. Moreover, parameters such as renal function, patient weight or left atrium remodelling are missing from the recommended guidelines scores. Vulnerable categories of patients including the elderly population, high hemorrhagic risk patients or patients with newly diagnosed paroxysmal episodes of atrial high rate at device interrogation are at risk of underestimation of the thrombotic risk. This review presents a systematic exposure of the most important gaps in evaluation of thrombotic and hemorrhagic risk in patients with NVAF. The authors propose new algorithms and risk factors that should be taken into consideration for an accurate thrombotic and hemorrhagic risk estimation, especially in vulnerable categories of patients.

Keywords: atrial fibrillation; genetics and inflammation in atrial fibrillation; hemorrhagic risk; left atrium remodelling; new risk scores; thrombotic risk.

Figure 1

(a and b) Example of LA shape changing due to 2 different angulations while searching for PV visualisation.

Figure 2

(a) An example of trapezoidal LA shape, LA basal diameter ˃ LA transversal diameter. (b) Practical example of LA tracing after (pulmonary vein) PV ostia definition and consecutive evaluation of shape remodelling. (c) The border of LA/PV is the line between each side of the intersection of a line tangential to the PV and LA walls.