Nonpharmacological Management of Atrial Fibrillation in Patients at High Intracranial Hemorrhage Risk.

Abstract

Despite significant advances in our ability to detect and treat atrial fibrillation (AF), less than half of high embolic risk patients receive oral anticoagulants (OACs).1 The main cause of this problem is the known association between OACs and intracranial hemorrhage (ICH), the latter being the most lethal and disabling condition known to humans, among the relatively common medical emergencies. The last decade saw the development and more recently the Food and Drug Administration (FDA) approval of an endovascular left atrial appendage closure (LAAC) procedure, namely WATCHMAN (Boston Scientific, Plymouth, MN; Figure 1), as a second-line treatment for stroke and systemic embolism prevention in nonvalvular AF (NVAF) without the need for lifelong anticoagulation. Other endovascular and surgical LAAC devices and procedures are currently being developed and tested in clinical trials. The other important advance has been the development of imaging markers that can help stratify the risk of ICH in individual patients. Current AF management guidelines recommend choosing the antithrombotic therapy based on shared decision-making approaches, after discussion of the absolute and relative risks of stroke and bleeding, taking into account the patient’s values and preferences.2 Table 1 and Figures 2 and 3 provide an overview of conditions that are associated with a relatively high ICH risk. In patients with NVAF and any of these high ICH risk conditions, LAAC might be considered for ischemic and hemorrhagic stroke prevention, taking into account the safety and efficacy of the device compared with OAC. View this table: Table 1. Conditions Associated With High Brain Bleeding Risk Figure 1. Select devices and procedures used for left atrial appendage closure (LAAC). A , Left , The WATCHMAN device (Boston Scientific, Plymouth, MN), FDA-approved for stroke prevention in nonvalvular atrial fibrillation through LAAC. Middle , Schematic showing the placement of WATCHMAN device in LAA, note septal puncture. Right , Schematic of …