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Recurrent Cardioembolic Stroke in Vascular Dementia Patient Co-existent with
Heart Failure and Atrial Fibrillation:
Oral Anticoagulant or Left Atrial Appendage Occluder?
Abraham Fatah1, Wendy Wiharja1, Raymond Pranata1, Sunanto Ng2
1
Faculty of Medicine, University of Pelita Harapan, Tangerang, Indonesia
Department of Cardiology Siloam Hospital Lippo Village, Tangerang, Indonesia
2
Introduction
Recurrence of cardioembolic stroke is high with increased in-hospital mortality rate
after previous event (27.3vs77%). Cardioembolic stroke is also associated with
hemorrhagic transformation. Dementia could result in poor compliance in taking
medicine. This is a dilemma where oral anticoagulant or left atrial appendage
occluder (LAAO) should be given for prevention of recurrence.
Case Report
A 64 y.o male with history of recurrent stroke, HF, HTN, and T2DM presented with
weakness on left side of his body for 2 days. Previous medications were valsartan,
nifedipine, bisoprolol, glibenclamide, and metformin. Recurrent stroke attack was
occurred 3x within 5 years with diagnosis of vascular dementia. Electrocardiography
showed atrial fibrillation (AF). Echocardiography showed LVEF 77.51% and
concentric hypertrophy of LV. Head CT-scan showed infarction located in left frontal
and right temporal lobes. CHA2DS2-VASc score was 5. HASBLED score was 3.
Warfarin was given and patient’s prognosis was bad.
Discussion
Risk of cardioembolic stroke in AF is increased with age from 1.5% at age 50 to 24%
at age 80, and AF is associated with first and recurrence of stroke. Recurrence more
commonly occurred within 3 months of initial event. Coexistent HF with AF carry
higher risk more than HF alone. Cardioembolic stroke is also associated with risk of
hemorrhagic transformation. Hence, this patient is at high risk both in recurrence and
complication. Stroke Prevention in Atrial Fibrillation (SPAF) study mentioned that
warfarin is indicated in AF patient with HF, history of HTN, and previous
thromboembolism. On the other hand, oral anticoagulant (OAC) increases risk for
intracerebral hemorrhage. Cardioembolic stroke with its consideration of higher risk
for hemorrhagic transformation, anticoagulant is only associated with small increase
of brain hemorrhage. Even though warfarin is indicated, LAAO might be considered
because of recurrent stroke episode even after warfarin was given; which could be
related to patient’s poor compliance due to unable to take medicine regularly and
difficulty monitoring of INR, which is associated with vascular dementia.
Conclusion
Recurrent episode of cardioembolic stroke carries higher risk of mortality. OAC is
recommended despite a small increase in hemorrhagic transformation, yet LAAO
should be considered in patient with poor compliance.
Keywords: Cardioembolic stroke, AF, HF, Oral anticoagulant