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2021 AF Symposium

Cerebral Amyloid Angiopathy (CAA) and Anticoagulants: Prevalence, Detection and Management

Dr. M. Edip Gurol

Background: For A-Fib patients, Dr. Mahmut Edip is a very important researcher. Many doctors consider anticoagulants as little more than a type of benign vitamin. Dr. Gurol’s studies and observations show how anticoagulants, particularly in older patients, can be dangerous drugs and contribute to brain bleeds.

Dr. Mahmut Edip Gurol from Massachusetts General Hospital in Boston, MA, gave a presentation about the role of anticoagulants entitled “Cerebral Amyloid Angiopathy (CAA): Prevalence, Detection and Management.

Anticoagulants Increase the Risk of Hemorrhagic Stroke!

In previous presentations, Dr. Gurol has shown that anticoagulants may actually increase the risk of Intracerebral Hemorrhage (ICH) stroke. Dr. Gurol’s images of cerebral microbleeds (CMBs) and the fatal strokes they can cause are a real wake-up call, especially to most older A-Fib patients. For more, see my article featuring Dr.Gurol: Anticoagulants Increase Risk of Hemorrhagic-Type Strokes

LEFT: Brain MRIs of two microbleeds in the same older adult with A-Fib taking a NOAC (red arrows point to tiny microbleed dots). RIGHT: Two years later, the patient had a hemorrhagic stroke and died. The right MRI shows the fatal hemorrhage.

“Angiopathy” means a disease of the blood vessels, especially where small blood vessels are damaged and burst open.
“Amyloid” is an abnormal protein produced in bone marrow that  can be deposited in any tissue or organ.

Cerebral Amyloid Angiopathy (CAA)

In his presentation at the 2021 AF Symposium, Dr. Gurol discussed Cerebral Amyloid Angiopathy (CAA) which is an accumulation of pathological amyloid beta proteins in superficial brain vessels.

Cerebral Amyloid Angiopathy (CAA) is a common cause of bleeding into brain tissue in older adults and is associated with a high risk of hemorrhagic recurrence. It contributes to age-related cognitive decline and is considered largely untreatable. CAA often accompanies Alzheimer’s disease.

CAA can be viewed in some ways as a canary in a coal mine [early warning signal] that may set in motion a damaging disease process.

Anticoagulants Can Affect CAA Causing Brain Bleeds and Increased Risk of Mortality

Dr. Gurol said that cognitive impairment and dementia are very prevalent in CAA patients. They are likely the result of brain injuries including cerebral microbleeds.

He referenced MRI studies that show that CAA can develop into Intracranial Hemorrhages (ICH) due to oral anticoagulant use.

In addition, Dr. Gurol discussed the increased mortality risk for patients on anticoagulants. As examples, he cited the mortality risk associated with the following:

▪ Warfarin 25% increased risk
▪ Rivaroxaban 14% increased risk
▪ Apixaban 5.4% increased risk

To avoid this increased risk of mortality, he recommended nonpharmaceutical approaches such as removal of or closing off the LAA for patients with CAA.

Dr. Gurol stressed the need for increased cooperation between stroke neurologists and EPs.

Editor’s Comments

Anticoagulants are High-Risk Drugs: Some pharmacists and doctors have always described anticoagulants as high-risk medications (Drs. Witt and Hansen).
Listening to Dr. Gurol makes the risk real, understandable, and relevant. You can’t argue when Dr. Gurol shows slides of microbleeds, describes how almost everyone over age 65 has them, then shows a photo of how deadly a hemorrhagic (brain bleed) stroke can be.
In MRI studies, 97% of patients taking NOACs had ICH markers. It’s all too easy for NOACs to expand these microbleeds into full blown Intracerebral Hemorrhages.
Should Patients Over Age 65 Be Taking Long-Term NOACs? Dr. Gurol and his colleagues did not say that people over 65 taking NOACs long-term will eventually develop Hemorrhagic strokes. But the chances of developing a Hemorrhagic stroke are alarmingly high. No one over age 65 should be taking long-term NOACs, unless there is no other option. The risk is simply too high. .

What Else Can You Do? …Remove the reason for an anticoagulant! Read about the three options to taking anticoagulants in my article: A-Fib Drug Therapy: Anticoagulant Side Effects and Alternatives.

Resources for this article

• Witt, Daniel W. and Hansen, Alisyn L. editorial in New Oral Anticoagulants Can Require Careful Dosing Too. by Scott Baltic. Medscape/Reuters Health Information, December 29, 2016. http://www.medscape.com/viewarticle/873821?src=wnl_edit_tpal

• Charidimou, A. et al. Emerging concepts in sporadic cerebral amyloid angiopathy. Brain, 2017 Jul; 1829-1850. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6059159/ doi: 10.1093/brain/awx047

If you find any errors on this page, email us. Y Last updated: Tuesday, April 20, 2021

Return to 2021 AF Symposium Reports

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