Silent cerebral infarcts in patients with atrial fibrillation: Clinical implications of an imaging-adjusted CHA₂DS₂-VASc score

Background: The CHA₂DS₂-VASc score does not include silent infarcts on neuroimaging in stroke risk estimation for patients with atrial fibrillation (AF). The inclusion of silent infarcts into CHA₂DS₂-VASc scoring and its impact on stroke prophylaxis recommendations in patients with AF has not been previ-ously studied. The present study sought to quantify the prevalence of silent infarcts in patients with AF and describe potential changes in management based on magnetic resonance imaging (MRI) findings. Methods: Participants from the Mayo Clinic Study of Aging with AF and brain MRI were included. Silent infarcts were identified. “Standard” CHA₂DS₂-VASc scores were calculated for each subject based on clinical history alone and “imaging-adjusted” CHA₂DS₂-VASc scores based on evidence of cerebral infarction on MRI. Standard and imaging-adjusted scores were compared. Results: One hundred and forty-seven participants (average age 77, 28% female) were identified with AF, MRI, and no clinical history of stroke. Overall, 41 (28%) patients had silent infarcts on MRI, corresponding with a 2-point increase in CHA₂DS₂-VASc score. Of these participants, only 39% (16/41) with silent infarct were on anticoagulation despite having standard CHA₂DS₂-VASc scores supportive of anticoagulation. After incorporating silent infarcts, 13% (19/147) would have an indication for peri-procedural bridging compared to 0.6% (1/147) at baseline. Conclusions: Incorporation of silent infarcts into the CHA₂DS₂-VASc score may change the risk--benefit ratio of anticoagulation. It may also increase the number of patients who would benefit from periprocedural bridging. Future research should examine whether an anticoagulation strategy based on imaging-adjusted CHA₂DS₂-VASc scores could result in a greater reduction of stroke and cognitive decline. (Cardiol J 2022; 29, 5: 766–772).