Abstract WP226: Clinical Uncertainty in Stroke Prevention for Atrial Fibrillation Patients at High Risk for Intracerebral Hemorrhage: Equipoise Among Vascular Neurologists

Background: Patients on direct oral anticoagulation (DOAC) for ischemic stroke prevention in atrial fibrillation (AF) who develop intracerebral hemorrhage (ICH) may either resume DOAC or not, depending on shared decision-making with a Vascular Neurologist. A non-pharmacologic alternative to DOAC is left atrial appendage closure (LAAC). It is unknown whether Vascular Neurologists prefer DOAC resumption or LAAC referral in specific patients at high risk of ICH. Aim: To investigate the decision-making strategies of Vascular Neurologists regarding DOAC use or LAAC referral in AF patients with ICH and/or at high risk of ICH. Methods: An online survey was emailed to a large clinical trial network database of Vascular Neurologists. Eight clinical scenarios were given with increasing complexity and ICH risk. Vascular Neurologists stated their preference for DOAC use versus LAAC for each case. Results: Overall, clinical equipoise was reported in 64.7% (77) of 119 Vascular Neurologists (70% male, 64% academic, 56% practiced over a decade), while 18.5% (22) reported no uncertainty in such decision-making, and 16.8% (20) were “Unsure.” The first 3 cases involved a 70-year-old, active, AF patient (CHA2DS2-VASc > 3) on a DOAC, with a small, medium, or large subcortical ICH, presumably related to hypertension. Respondents answered, respectively, to resume DOAC (49.6%, 31.4%, 23.7%), consider LAAC with antiplatelet (AP) (10.9%, 22.0%, 33.9%), or LAAC with DOAC (34.5%, 42.4%, 36.4%). The next 3 cases involved an AF patient with dementia and a few (3-5) or many (>5) cerebral microbleeds (CMB) without prior ICH, or lobar ICH with CMBs, all presumably related to cerebral amyloid angiopathy (CAA). Respondents respectively, would: choose a different DOAC (1.7%, 1.7%, 1.7%), resume same DOAC (33.3%, 16.2%, 0.9%), stop DOAC and use AP only (5.1%, 8.5%, 6.8%), use neither AP nor DOAC (1.7%, 2.6%, 6%); refer for LAAC with AP (15.4%, 32.5%, 49.6%) or refer for LAAC with DOAC (42.7%, 38.5%, 35.0%). Conclusions: Managing AF patients after ICH or at high risk for ICH is a challenge. No clear standardized approach exists and clinical uncertainty is high regarding DOAC use or LAAC referral. Vascular Neurologists favored LAAC as ICH severity increased or CAA was suspected, however many resumed DOAC in medium-risk scenarios such as hypertension etiology or smaller ICH. This highlights the need for further data to guide therapy in various risk strata for AF patients with ICH.