Atrial fibrillation type and renal dysfunction: new challenges in thromboembolic risk assessment

One of the most feared complications in atrial fibrillation (AF), an epidemic disease associated with increased comorbidities and subsequent mortality, is stroke and/or systemic embolism related to left atrial and especially left atrial appendage thrombus formation. Besides stroke and systemic emboli, heart failure and death are equally feared complications in this arrhythmia. AF is associated with left atrial structural remodelling (atrial fibrosis) and hypercoagulability status; both may cause and promote AF due to the atrial cardiomyopathy occurrence.1 Therefore, left atrial thrombus could be the result of this vicious circle associated with this thrombogenic cardiomyopathy.1 Nowadays it is well known that thromboembolic risk scores (CHA2DS2-VASc - C: congestive heart failure; H: hypertension; A: age 75 years or older; D: diabetes mellitus; S: stroke, transient ischemic attack, or systemic throboembolism (including any history of cerebral ischemia); V: prior myocardial infarction, peripheral arterial disease, or aortic plaque; A: age 65 to 74 years; Sc: sex category (female); and CHADS2 - C: congestive heart failure; H: hypertension; A: age 75 years or older; D: diabetes mellitus; S: stroke, transient ischemic attack or systemic thromboembolism (including any history of cerebral ischemia) recommended by the guidelines have a suboptimal predictive accuracy in patients with AF before anticoagulation treatment. Moreover, transoesophageal echocardiography seems to be indicated in patients with non-paroxysmal AF (persistent, long-lasting persistent and/or permanent) and high thromboembolic risk, as assessed by both scores, despite having received correct anticoagulation therapy. An ideal thromboembolic risk assessment tool allowing clinicians accurate patient selection and appropriate risk stratification has yet to be created. Since its first incorporation in the 2010 guidelines, CHA2DS2-VASc has been recommended in non-valvular AF irrespective of AF type (paroxysmal vs non-paroxysmal AF). The paper by Kaplon-Cieślicka et al entitled: ‘Atrial fibrillation type and renal dysfunction as important predictors of left atrial thrombus’ might open a new …