An 84 year-old woman with hypertension, chronic obstructive pulmonary disease, and chronic renal insufficiency (estimated glomerular filtration, rate 38 mL/min/1.73 m2) also has paroxysmal atrial fibrillation (AF) with a CHADS2 score of 4 and CHA2DS2-VASc score of 6. She suffered a stroke a year ago and was treated with tissue plasminogen activator. This was complicated by hemorrhagic transformation, resulting in expressive dysphagia. Given her history of intracranial hemorrhage, she was deemed to be a poor candidate for long-term oral anticoagulation (OAC) and was thus referred for endovascular left atrial appendage (LAA) closure. Under general anesthesia and transesophageal echocardiography (TEE) guidance, a 28-mm Amplatzer Cardiac Plug (ACP; St. Jude Medical, St. Paul, MN) was successfully deployed. The patient was discharged the following day with no complication and was commenced on dual antiplatelet therapy (aspirin 81 mg/d and clopidogrel 75 mg/d) for 3 months, followed by aspirin indefinitely.
AF is the most common cardiac arrhythmia. It affects 1% of the general population, 6% of people over the age of 65 years, and 9% of people over the age of 80 years.1,2 With the aging population, the prevalence of AF is set to increase, and its impact on the health system is also projected to increase substantially.3,4
AF is associated with considerable morbidity and mortality. One of the major feared morbidities associated with AF is stroke. AF is an independent risk factor for stroke, occurring in up to 19% of stroke patients over the age of 70 years.5 After adjusting for other risk factors, AF is associated with a 4- to 5-fold increased risk of ischemic stroke.5 Paroxysmal AF carries a similar risk of stroke as patients with permanent AF.6 Cardioembolic strokes associated with AF are generally more severe than other types of ischemic stroke and have been associated with higher 30-day and 1-year mortality.7,8 The CHADS2 and the CHA2DS2-VASc were developed as risk models to estimate risk of stroke (Tables 30-1 and 30-2) and are widely adopted in clinical practice. It is estimated that there are 800,000 strokes each year in the United States, with 1.5% of those attributed to AF in those under age 59 and 23% attributed to AF in those greater than age 80.5 Stroke is the number 1 cause of major morbidity in the United States and estimated to cost the healthcare system approximately $30 billion each year.
Table 30-1CHADS2 Score ||Download (.pdf) Table 30-1 CHADS2 Score
| ||Score |
|Congestive heart failure ||1 |
|Hypertension ||1 |
|Age ≥75 years ||1 |
|Diabetes ||1 |
|Stroke ||2 |
|Score ||Risk of Stroke/100 Person-Years |
|1 ||2.8% |
|2 ||4% |
|3 ||5.9% |
|≥4 ||≥8.5% |