A fine balance: anticoagulation for non-valvular atrial fibrillation after cerebral amyloid angiopathy–related intracranial haemorrhage

The management of anticoagulation in patients with non-valvular atrial fibrillation at high risk of bleeding complications can be challenging. One such group is elderly patients with previous intracranial haemorrhage secondary to cerebral amyloid angiopathy (CAA-ICH). These patients have a high rate of rebleeding, which can be predicted by features on cerebral magnetic resonance imaging. Common bleeding risk calculators, such as the HAS-BLED score, underestimate the bleeding event rate in patients with CAA-ICH due to poor patient representation in validation studies. Observational studies and subgroup analyses of small randomised controlled trials have failed to show conclusive evidence of benefit or harm with restarting anticoagulation after CAA-ICH. The results of larger, dedicated randomised controlled trials are eagerly awaited. An alternative to anticoagulation in patients with CAA-ICH and concomitant high ischaemic stroke risk is left atrial appendage closure, which has been shown to be effective in this subgroup. This narrative review will use a case to discuss the currently available evidence on this important topic, given our ageing population.