By M. Asim Shabbir, MD
A 73-year-old woman with a history of hypertension, heart failure with preserved ejection fraction, gross hematuria, anemia, ischemic stroke 6 months prior, and atrial fibrillation (AF) off anticoagulation secondary to hematuria came to our clinic
to be evaluated for left atrial appendage closure (LAAC) to reduce risk of stroke from AF. She had a high CHA₂DS₂-VASc score of 6 (age>65, female gender, stroke, hypertension, HfpEF) and 99% AF burden on a 30-day cardiac monitor.
Challenge for FellowsUse a CardioSmart tool with 5 patients and submit an essay about your experience to your Program Director. If your narrative effectively shows Shared Decision-Making in action, you could be 1 of 3 winners. Visit
CardioSmart.org/Challenge for more information.
Given significant AF burden and high CHA₂DS₂-VASc score in the setting of recent stroke, her annual risk of stroke/transient ischemic attack/systemic embolism was calculated at 13.6%. Since she could not take long term anticoagulation due to hematuria, she was referred to our structural heart disease clinic for evaluation for LAAC.
Support for talking about risk
The patient was reluctant to get LAAC due to poor understanding of her risk for recurrent stroke. At this point, a CardioSmart tool explaining stroke prevention for patients with AFib considering an LAAC device was very helpful in reviewing the following with the patient:
- Her risk of recurrent stroke with and without treatment
- Available options to reduce risk of stroke
- Risks and benefits of treatment with blood thinners vs. LAAC, and details of the procedure
After reviewing this information together, she decided to follow up in a week to discuss the plan further. At her follow-up appointment, the patient decided to undergo LAAC and resumed her rivaroxaban (direct oral anticoagulant) in the short term with close monitoring for hematuria. We counseled her about
continuing anticoagulation in the short-term after the LAAC procedure. She underwent LAAC within two weeks. Afterward, she expressed gratitude to our team, and we are thankful to ACC CardioSmart for this wonderful tool.
Through this experience, I learned the importance of shared decision-making with patients regarding therapeutic options, and Cardiosmart tools can be extremely helpful in the process. These tools can make a difference not only in a patient’s life
but also for physicians helping patients to make decisions about their care.
M. Asim Shabbir, MD, is a cardiovascular disease fellow at the University of Nebraska Medical Center in Omaha, NE.