AF Anticoagulation in HCM — EECC MCQ

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ModerateArrhythmia & ElectrophysiologyAF Anticoagulation in HCMEECC

A 45-year-old man with HCM develops paroxysmal AF. His CHA₂DS₂-VA score is 0 (age <65, no HTN, diabetes, vascular disease, stroke, or HF). The 2024 ESC AF Guidelines recommend anticoagulation based on CHA₂DS₂-VA score. However, what special consideration applies to AF in HCM?

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Correct answer: D — HCM with AF carries a high thromboembolic risk regardless of CHA₂DS₂-VA score — the ESC recommends anticoagulation for ALL HCM patients who develop AF, irrespective of the CHA₂DS₂-VA score

AF in HCM carries a particularly high thromboembolic risk (~5-10% per year for stroke/TIA, even in patients with CHA₂DS₂-VA 0) due to: (1) left atrial enlargement and stasis; (2) diastolic dysfunction reducing LA emptying; (3) LVOT obstruction causing turbulent flow; (4) prothrombotic state (endothelial dysfunction). The 2023 ESC Cardiomyopathy Guidelines and 2024 AF Guidelines recommend: anticoagulation for ALL HCM patients with AF, regardless of CHA₂DS₂-VA score (Class I). DOACs are preferred over warfarin. This is one of the few situations where anticoagulation is recommended irrespective of the standard risk scoring system. Additionally, rhythm control is generally preferred in HCM (AF is poorly tolerated due to the stiff, non-compliant LV depending on atrial contraction for filling).

Reference: ESC (2023): Cardiomyopathies; ESC (2024): AF Guidelines