Strategies to balance stroke and bleeding risk in patients with atrial fibrillation and cancer

A 76-year-old woman with obesity, hypertension, persistent atrial fibrillation (AF), and heart failure with preserved ejection fraction is started on ibrutinib 420 mg once daily for Waldenstrom macroglobulinemia. Due to concern for drug–drug interactions, her amiodarone dose is decreased from 200 to 100 mg daily, and she is continued on metoprolol succinate 100 mg daily and apixaban 5 mg twice daily. She presents to the clinic 1 month later with extensive superficial ecchymoses, and her apixaban dose is reduced to 2.5 mg twice daily due to concern that this presentation may reflect the combined antiplatelet effects of ibrutinib and anticoagulant effects of apixaban. The patient is then admitted with headaches, and magnetic resonance imaging of the brain MRI shows a small intracranial hemorrhage of unclear duration. Given the need for stroke prophylaxis (CHA2DS2-VASc score 5) and risks associated with continued anticoagulation (HAS-BLED score 3), the patient is referred for a Watchman® (Boston Scientific, Marlborough, MA) device.