158 Management of Atrial Fibrillation in Patients with Cerebral Amyloid Angiopathy: Multidisciplinary Neuro-Cardiology Approach

Abstract

We present two cases that highlight the clinical challenge of anticoagulation in patients with intracerebral haemorrhage (ICH) dueto Cerebral Amyloid Angiopathy (CAA) and co-existent non-valvular Atrial Fibrillation (AF). Case 1 78-Years right-handed functionally independent gentlemanpresented with right parietal intracerebral haemorrhage (ICH) onDabigatran that required reversal. He had a background history of hypertension, persistent AF and a previous ICH on warfarin. Postatrial septal defect repair, he had multiple unsuccessfulcardioversions for AF, and a failed catheter ablation after the firststroke. Magnetic Resonance Imaging (MRI) brain showed CerebralAmyloid Angiopathy (CAA), the cause of his recurrent bleeds.Anticoagulation was not started due to severe CAA on imaging and recurrent bleeds. He was referred for left atrial closure device. Case 2 79-Years female presented with left parietal haemorrhage and new onset atrial fibrillation. Work up for ICH showed normal BPreadings and clotting profile. Her MRI brain showed a large lobarbleed with mild small vessel disease and evidence of no otherimaging features suggestive of CAA. As optimal timing to startanticoagulation after ICH is unknown, she was suggested to takepart in a clinical trial. Her family declined the offer of clinical trial and also anti coagulation due to few falls. Her CHAD-VaSc and HAS-BLED score were 4 and 2 respectively. She was then referredto tertiary centre for left atrial appendage closure device. Conclusion Safety and timing to initiate DOAC for AF in this group is notestablished yet, understanding hemorrhagic risk using BostonCriteria for CAA diagnosis should be considered in addition toHAS-BLED score. Shared decision making and comprehensivediscussions with cardiologist are of paramount importance. Nonpharmacological intervention studies WATCHMAN and PREVAILhave proven procedural efficacy, however, in elderly population,decision making is complex due to frailty, dementia and co-morbidities.