What is the recommended anticoagulation prophylaxis for patients with cerebral amyloid angiopathy (CAA) on Aspirin (acetylsalicylic acid) with a high risk of falls?

Anticoagulation Prophylaxis for Patients with CAA on Aspirin with High Falls Risk

For patients with cerebral amyloid angiopathy (CAA) on aspirin with high falls risk, anticoagulation should be avoided and left atrial appendage occlusion (LAAO) should be considered as the preferred alternative if stroke prevention is needed.

Risk Assessment for CAA Patients

CAA significantly increases the risk of intracranial hemorrhage with any form of anticoagulation therapy. The 2014 American Heart Association/American Stroke Association guidelines specifically note that "a history of lobar ICH suggestive of cerebral amyloid angiopathy" is a risk factor that appears "sufficient to tip the balance away from anticoagulation in nonvalvular AF" 1.

Key considerations in these patients:

• Bleeding risk: CAA dramatically increases risk of lobar hemorrhage with anticoagulants
• Falls risk: Further compounds bleeding risk, especially intracranial hemorrhage
• Current aspirin therapy: Already provides some thrombotic protection but with lower bleeding risk than anticoagulants

Management Recommendations

First-line Approach

• Discontinue aspirin if there is no compelling indication (such as recent coronary stenting)
• Avoid all oral anticoagulants (DOACs and warfarin) due to prohibitively high bleeding risk 1, 2
• Consider left atrial appendage occlusion (LAAO) for patients with atrial fibrillation who need stroke prevention 2, 3

Alternative Options (if LAAO not feasible)

• Single antiplatelet therapy:
  • Clopidogrel 75mg daily (preferred over aspirin) 1
  • Continue aspirin 75-100mg daily (if already tolerated) 1

Risk Modification Strategies

• Aggressive blood pressure control (reduces ICH risk by up to 77% in CAA patients) 4
• Fall prevention measures including physical therapy, home safety evaluation, and assistive devices
• Avoid statins if patient has history of lobar ICH (increases recurrent hemorrhage risk from 14% to 22%) 4

Evidence Supporting LAAO in CAA

A cohort study of 26 patients with severe CAA and atrial fibrillation who underwent LAAO showed promising results 3:

• No documented ischemic strokes or symptomatic ICH during the 30 days after device implantation
• Only one ischemic stroke during 25-month average follow-up
• No other thromboembolic events in the cohort

Special Considerations

For Patients with Recent Coronary Intervention

If the patient has had recent coronary stenting and requires dual antiplatelet therapy:

• Minimize duration of dual therapy to the shortest effective period
• Consider early cessation of aspirin (≤1 week) and continuation with clopidogrel alone 1
• Avoid triple therapy (dual antiplatelet plus anticoagulant) 1

For Patients with Mechanical Heart Valves

These patients present a particularly challenging scenario:

• Consider referral to specialized centers with experience in managing such complex cases
• Surgical valve replacement with a bioprosthetic valve might be considered to eliminate the need for long-term anticoagulation

Common Pitfalls to Avoid

1. Initiating anticoagulation despite CAA diagnosis (extremely high bleeding risk)
2. Continuing dual antiplatelet therapy longer than absolutely necessary
3. Failing to implement fall prevention strategies
4. Overlooking LAAO as a viable alternative for stroke prevention in AF patients
5. Inadequate blood pressure control (critical for reducing hemorrhage risk)

The management of these patients requires careful balancing of thrombotic and hemorrhagic risks, but the evidence strongly suggests that avoiding anticoagulation and considering LAAO offers the best approach to reducing morbidity and mortality in patients with CAA and high falls risk.