Cardioembolic stroke risk in hypertrophic cardiomyopathy: role of anticoagulation—a systematic review

Abstract

Hypertrophic cardiomyopathy (HCM) is a genetic disorder characterized by myocardial hypertrophy, diastolic dysfunction, and a high risk of atrial fibrillation (AF) and stroke. AF is the most common arrhythmia in HCM and a key driver of cardioembolic events. However, anticoagulation strategies are inconsistently applied, especially in patients without documented AF but with other risk factors such as left atrial enlargement. This systematic review, conducted according to PRISMA guidelines, analyzed observational and case–control studies published from 2000 to 2023 in PubMed, Embase, Scopus, and Web of Science. Fifteen studies including 90,661 HCM patients were evaluated. AF prevalence ranged from 10 to 45.1%, and stroke incidence from 0.5 to 22.4%, with annualized rates of 0.5–1.78%. Risk factors for stroke included advanced age, prior TIA/stroke, heart failure, and left atrial enlargement. Both warfarin and direct oral anticoagulants (DOACs) effectively reduced stroke risk with comparable safety profiles. AF markedly increases stroke risk in HCM, underscoring the need for individualized anticoagulation strategies. Risk stratification incorporating CHA2DS2-VASc score, left atrial size, and clinical characteristics is essential for optimizing prevention and management.