Current prac- tice based on clinical trial design involves short- term (1.5 months) use of oral anticoagulation after Watchman device placement to reduce the risk of device-related thrombus followed by 4.5 months of DAPT. In patients at high bleeding risk from oral anticoagulation, left atrial appendage closure can reduce the long-term risk of bleeding with an isch- emic stroke risk comparable to that of anticoagula- tion with VKA. 9. Cerebral infarction weakens the blood brain bar- rier, increasing the risk of spontaneous hemor- rhage after acute ischemic stroke, yet patients with stroke or TIA in the setting of AF are at increased risk of recurrent stroke.428 Anticoagulation reduces the risk of recurrent embolism but increases the risk of cerebral hemorrhage during the acute post- The optimal timing of initiating oral anticoagulation should be individualized for each patient s risk of hemorrhage versus recurrent embolism. Although the annualized risk of recurrent stroke can be significant, the daily risk of embolism from AF is generally small. For example, a patient with a 6% risk of stroke over 1 year would have a daily risk of 0.016% and a risk of 0.23% over 14 days. Nevertheless, an analysis of the VISTA cohort study (Virtual International Stroke Trials Archive) of 1644 patients found fewer recurrent strokes with initiation of VKA 2 to 3 days after stroke compared with >3 days without increased risk of symptom- In patients with larger cerebral infarcts, evidence of hemorrhage on neuroimaging, NIHSS score >9, or other features that place them at increased risk of hemorrhagic conversion after acute stroke, the balance of risk and benefit favors waiting for healing and reduced bleeding risk.429 10. Patients with renal failure on dialysis are at increased risk for both bleeding and thrombotic events. 