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THE DILEMMA OF BLEEDING DURING AF TREATMENT

THE DILEMMA OF BLEEDING DURING AF TREATMENT. M. Edip Gurol, MD, MSc Director , High Hemorrhage Risk Stroke Prevention Clinic Massachusetts General Hospital Harvard Medical School. DISCLOSURE STATEMENT OF FINANCIAL INTEREST.

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THE DILEMMA OF BLEEDING DURING AF TREATMENT

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  1. THE DILEMMA OF BLEEDING DURING AF TREATMENT M. Edip Gurol, MD, MSc Director, High HemorrhageRiskStrokePreventionClinic Massachusetts General Hospital Harvard Medical School

  2. DISCLOSURE STATEMENT OF FINANCIAL INTEREST I, (M. Edip Gurol) DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. Funding from NIH (NS083711)

  3. Gurol Stroke 2018 Jan;49(1):247-254

  4. WHY ICH RISK MATTERS IN NVAF? • Oral Anticoagulants (incl. NOACs) increase ICH risk • Outcomes of OAC (incl. NOAC) related ICH are extremely poor • ICH risk can be determined BEFORE it happens even in asymptomatic patients • Brain microbleeds on MRI • White matter disease on MRI • Cognitive/gait problems • Consider nonpharmacological alternatives such as LAAC for ischemic and hemorrhagic stroke prevention in NVAF patients at higher ICH risk

  5. Stroke. 2012;43:3291-3297

  6. WHY ICH RISK MATTERS IN NVAF? • Oral Anticoagulants (incl. NOACs) increase ICH risk • Outcomes of OAC (incl. NOAC) related ICH are extremely poor • ICH risk can be determined BEFORE it happens even in asymptomatic patients • Brain microbleeds on MRI • White matter disease on MRI • Cognitive/gait problems • Consider nonpharmacological alternatives such as LAAC for ischemic and hemorrhagic stroke prevention in NVAF patients at higher ICH risk

  7. Outcomes of NOAC-related ICH Gurol Stroke 2018 Jan;49(1):247-254

  8. WHY ICH RISK MATTERS IN NVAF? • Oral Anticoagulants (incl. NOACs) increase ICH risk • Outcomes of OAC (incl. NOAC) related ICH are extremely poor • ICH risk can be determined BEFORE it happens even in asymptomatic patients • Brain microbleeds on MRI • White matter disease on MRI • Cognitive/gait problems • Consider nonpharmacological alternatives such as LAAC for ischemic and hemorrhagic stroke prevention in NVAF patients at higher ICH risk

  9. Gurol Stroke 2018 Jan;49(1):247-254

  10. Warfarin use and older age were independent predictors of future IPH in lobar MB-only patients after correction for other covariates

  11. Out of 1490 pts (age 76+10) w/ NVAF who had MRI before starting OAC 21% had brain microbleeds

  12. Trial was stopped at the first interim analysis Excess of the primary outcome event in the anticoagulated group (81 of 651) versus 36 of 665 in the aspirin group (hazard ratio, 2.3; 95% confidence interval [CI], 1.6-3.5). This excess could be attributed to 53 major bleeding complications (27 intracranial; 17 fatal) during anticoagulant therapy versus  6 on aspirin  (3 intracranial; 1 fatal).

  13. WHY ICH RISK MATTERS IN NVAF? • Oral Anticoagulants (incl. NOACs) increase ICH risk • Outcomes of OAC (incl. NOAC) related ICH are extremely poor • ICH risk can be determined BEFORE it happens even in asymptomatic patients • Brain microbleeds on MRI • White matter disease on MRI • Cognitive/gait problems • Consider nonpharmacological alternatives such as LAAC for ischemic and hemorrhagic stroke prevention in NVAF patients at higher ICH risk

  14. Patient 73M HTN, DM2; HPL, CAD s/p 2V CABG; CHF, PAFib, s/p cardioversion, on Coumadin TIA? 1997

  15. Patient TIA? 1997 TND 2003

  16. Patient TIA? 1997 TND 2003 2010

  17. https://www.brainbleed.com/

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