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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