Cardiomyopathy, reduced EF, CHF and stroke

Pearls
1. Cardiomyopathy is second most common cause of cardioembolic stroke with a 3/ relative risk.

2. Ventricular thrombus occurs is 3-4 % of dilated cardiomyopathy with an annual risk of systemic embolism of 3-4 %. Further risk factors for emboli are stasis, low ventricular flow velocity, and hemostatic abnormalities and low EF.

3. CHF has an annual stroke risk of 1-4 % and anticoagulation is recommended for EF of < 35 % regardless of cause. WARCEF will study warfarin v. aspirin for this indication.

4. RHD with valve disorder has 1.5 to 4.7 % annual risk of emboli, with 12 % presenting with emboli as first sign of. 30-65 % of cases have recurrent emboli, usually within 6-12 months. Anticoagulation reduces annual stroke risk in old observational studies from 10 to 0.8-3 %.

5. MVP has stroke risk in young adults of about 1:6000.

6. Mitral annular calcification has 2.1 increase stroke risk and associates with AF.

7. Mechanical valves embolize at a rate of 2-4 % /year WITH anticoagulation. Further risk factors of thrombus formation are LAE, atrial stasis, AF, valve type and position (tilting disc), and in one study ventricular pacers.

8. Patients with bioprosthetic valves without anticoagulation have a risk of emboli of 6% in first 3 months.

9. Combined therapy of antiplatelet plus anticoagulation therapy risk is 1.3 to 24.7 % for major hemorrhage.

10. Anticoagulation may be continued in setting of infective endocarditis although opinion is divided on efficacy in this setting.