Atrial fibrillation and thromboembolic risk in hypertrophic cardiomyopathy.

Abstract

Atrial fibrillation (AF) is the most common sustained arrhythmia in patients with hypertrophic cardiomyopathy (HCM), conferring a markedly increased risk of thromboembolic events. Conventional risk stratification tools such as the CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥ 75 years [doubled], diabetes mellitus, prior stroke or transient ischemic attack [doubled], vascular disease, age 65-74 years, female sex) score are often insufficient to predict thromboembolic events in patients with HCM and AF, as thromboembolic risk in HCM is driven by disease-specific structural, functional, and prothrombotic substrates. This review synthesizes current evidence on the epidemiology, pathophysiological mechanisms, and clinical impact of AF and thromboembolism in HCM. We discuss variable imaging modalities-including strain echocardiography, cardiac magnetic resonance, and cardiac computed tomography-that offer enhanced characterization of atrial remodeling and thromboembolic risk in patients with HCM. Furthermore, we outline current guideline-based anticoagulation strategies, the evolving role of direct oral anticoagulants, and adjunctive therapies such as left atrial appendage occlusion and catheter ablation. A comprehensive, multidisciplinary approach that incorporates advanced imaging, molecular profiling, and individualized management is ideal to optimize outcomes and reduce stroke burden in patients with HCM and AF.