CHADSVASC of Zero But With History of AF - Is An Anticoagulant Recommended?

[Drounding]

I have a question or two that perhaps someone can comment on......

I have Paroxysmal AF and mainly get just short episodes of AF every few weeks or so that either correct themselves or that I take Flecainide PIP for. I have however had two conversions in A&E over a few years; the first corrected by IV Flecainide; the second an Electro-cardioversion. Both were successful at the time and were done within a few hours of the AF being Persistent. I.e. I presume when there was a lower risk of a clot forming and being released.

I am on Aspirin (I know!). My CHADSVASC score is zero. I'm 58 with no other conditions that would increase the score. This means according to the guidelines the risk associated with bleeding is higher than the risk of stroke.

However - should my short episodes of AF and in particular my episodes of Persistent AF and the need to be converted be taken into consideration? In other words should I be on Warfarin or a NOAC because of my AF history even with CHADSVASC of zero?

Another related question.......

I understand that Aspirin is not effective as a prevention of AF related stroke. Is it safe to suddenly stop taking the Aspirin, should I reduce it slowly over time, or should I wait until (or if) I start an anticoagulant? (I tolerate the Aspirin well I think, and always take it with food)

I want to go and discuss these things with my GP but before doing so would like to hear peoples opinions on this.

Thanks!

[rosyG]

very tricky questions!!

I'm going to leave it to those who are your age but have decided to be anticoagulated to answer!! I was talking to a stroke consultant today who said bits of clots from AF build up over time and lodge in the atrial appendage and when one goes back into NSR the force ejects the clot. Not an answer to your question but may be relevant?

[Drounding in reply to rosyG]

It is relevant in a way and explains why the consultant in A&E said that they would try an electro cardioversion there and then whilst the chance of a clot releasing was lower.

I know the questions are a bit tricky which is why I would like some info before approaching my GP.

[Hidden]

In answer to your second query.....I took aspirin daily for about 15 years before I was put on Warfarin 12+ years ago. There was no phasing out of aspirin. I simply stopped it. I was about 58 when I went over to Warfarin. I had mainly persistent ( not permanent ) fast AF & had several DC cardioversion by that time.

Sandra

[BobD Volunteer]

This is actually a very emotive question and it was discussed at our Patients Day on Sunday. Current guidelines do not recommend anticoagulation if you have a Chadsvasc score of zero but many doctors feel that this is wrong. It is really a question of balance as to your risk of stroke against your risk of bleeding and to be honest I think it should be a personal choice. I was 64 when my last ablation proved successful and my EP said I could stop warfarin. I declined and continue to this day regardless of no AF.

It should be pointed out that CHADSVASC only applies to people with AF as there is no stroke predictor for those with normal electrical systems but that frequency or intensity of event is not relevant to that risk. You could have one event and have a stroke or be in persistent AF and not have one. There is also a body of opinion which feels that the changes which AF create within the heart may allow the formation of clots even when there is no AF event in progress or after a successful ablation.

Until such time as further study produces a compelling case for anticoagulation for all AF patients regardless of any scoring system that is what we are stuck with although there is some research into better predictors.

I would remind you just in case that when working out CHADSVASC one must include any condition which is controlled. For example even if your BP is under 140/90 but you are on medication for it then you have a score of 1. Once given a score cannot be removed in other words.

Just ditch the aspirin unless you have another cardiac condition seems to be the way.

Bob

[jeff1257 in reply to BobD]

Bob,

Are you sure that "once given a score cannot be removed?" I've been trying to find a discussion of hypertension that has now resolved due to weight loss, not medication. Is the CHADS2 risk factor any history of hypertension or current hypertension? So far, I have found no paper on point.

[BobD Volunteer in reply to jeff1257]

It has always been historic regardless of current situation. Sad I know but true.

[jeff1257 in reply to BobD]

Thanks! Any paper you can point me to? Neither of my two cardiologists has been able to answer this.

[BobD Volunteer in reply to jeff1257]

Try googling Prof Gregory Lip who designed the system.

[jeff1257 in reply to BobD]

You are indeed correct, it is any history of hypertension. Thanks for the information.

[rosyG in reply to jeff1257]

I think the score does change- I have heard consultants say that is why we should be reviewed. If hypertension has been resolved through diet etc one can't be said to still be suffering from it- of course Bob is right if one is just taking meds for it as the underlying factors leading to it are still present.

[BobD Volunteer in reply to rosyG]

see above

[jeff1257 in reply to rosyG]

Actually, I corresponded with Professor Lip and he confirmed that for the CHADS-VASc score, it's history of hypertension that counts as a risk factor. However, for purpose of HAS-BLED, controlled hypertension negates that risk factor when assessing bleeding risk. Here is a link where Professor Lip talks about this: youtube.com/watch?v=bKeiLfw...(Not working as expected?)

[rosyG in reply to jeff1257]

It's interesting- maybe if hypertension has been so bad that it's caused damage to blood vessels this is why it still is counted- i know many doctors think it reduces stroke risk markedly if hypertension is eliminated naturally- I've been looking into this s have to stop Apixaban for a procedure so I'm hoping they are being truthful about my stroke risk having reduced along with reduction in BP !

[Susiebelle in reply to jeff1257]

InMay 2010 Iwas diagnosed with AF- put onwarfarinbut awaiting cardio version.

In the October of that year I went for a cardio version but was found to be in NSR. The warfarin was stopped.

In the December I had a full stroke.

Put back on warfarin in January 2011.

[Hidden]

Not a direct answer but may be of interest .........My approach is reduce the risk of a stroke by looking at your diet and exercise. I am CHADS 0 and my cardiologist suggested I postpone NOACs until I am 65 (currently 62), I was happy to agree.

I think a significant factor is your diet/supplements (some nations have very low stroke incidence) and therefore I take Krill oil supplement and quite a bit of good quality organic olive oil. I also have reduced my sugar intake by 50%+ as I believe (not sure about it technically) sugar increases the viscosity of the blood and is no good for you anyway. On exercise, I do regular x2 brisk walks a day, 1 mile each and on car journeys take a break every 90 mins - I think this is better than extreme exercise and then nothing for a couple of days. I have a desk job and in a Home office so can take regular exercise breaks there. I rarely am sedentary in from of any screen for more than an hour.

I hesitate to add in another issue but on getting a blood clot in my leg 15 years ago after a 5 hour rainy (i.e. stressful, which is contributory) car journey, I was tested and found to have Factor V Leiden heterogenous. This is a defective gene in the blood condition, which means you clot more readily, apparently 15% of the population has it and most don't know. Fortunately I have the hetero version and not the homo version, the latter clots sooner of the two.

[Drounding]

Thsnks Bob. I was also at the Patients Day on Sunday (Great day BTW) when this was discussed. It triggered my thinking and afterwards I wasn't sure what I'd heard (too much thought perhaps). You've clarified things.

I will go and see my GP and see what his assessment of the risks are vs what I would prefer.

[Therealsue]

Hi Drounding. In your situation, as Bob says, its a very personal choice. I'm 59 now but was 57 when I went onto Anticoags ready for (a successful) ablation. Before that, with paroxysmal AF that was getting worse, I wasn't on any medication at all. After the ablation, my EP kept me on AC's for around six months after which my he said I could stop taking them as my score is only 1 (because of being female). I decided, however, to stick with them and changed from warfarin to rivaroxaban and am very happy with it. Although my EP said I didn't really need them, he wasn't against me staying on them either if it made me feel happier. It's a bit of a grey area really. Good luck with your decision.

[Tototcx]

I'm 57 with a chadsvasc score of zero too as the point for being female under 60 is nullified for age . I don't take any anticoagulation either. I was told by my EP this week that because my episodes don't last very long there isn't enough time for a clot to form so there's no need. I'm very symptomatic and know the instant it starts and stops . I seem to get short, quite violent episodes!

But everyone's story is unique to some extent and without a full history I wouldn't comment on your situation ...only mine . Hope this helps.

[BobD Volunteer]

The bottom line is that although Prof Lip and his team improved the predictor by going from CHADS2 to CHADSVASC it is still an imprecise tool. Not all doctors or EPs really fully understand this and guidelines stress that it should be a personal choice by the patient after due discussion, not a case of "you don't need this". There was a Patient Decision Aid produced about 18 months ago which I think is available from CareAF website which although somewhat unwieldy is actually very good.

[AnticoagulateNow]

It's important to understand that the risk 'twixt stroke and bleeding is not an even one. It's not as simple as do one thing and the chances are such and such you'll have a stroke - do the other and those same chances are that you'll bleed to death. At your age especially, these risks are not 'balanced'. The risk significantly favours stroke over bleeding. To spell it out, there is a much greater chance (it seems to be somewhere between 3 and 5% per annum) that you will have a stroke/TIA if you are not on anticoagulants than there is of you having a life-threatening bleed if you are taking an anticoagulant (less than 1% at age 65, though the bleed risk does increase with continued aging). Note, I'm not talking about the odd nose bleed or bleeding gums or the small gardening wound that's 'taking it's time'. I'm talking about those bleeds that have the potential to be as medically serious as a stroke or TIA.

So to answer your question with a question.......why not?

[Drounding]

Many thanks for all the comments. It all helps me keep perspective around my thoughts before discussing it.

[Robert185 in reply to Drounding]

Hi I was give a score of 0 I am 55 and had a stroke in January, I was fortunate and recovered well. I was told to just take asprin before I had the stroke. I am now on rivaboxban and have been told I will stay on it for life. I have an ablation on Fri and even if successful I won't come off rivaboxban which I am happy about.

Rob.

[rosyG in reply to Robert185]

good luck for friday!

[Robert185 in reply to rosyG]

Thank you

[Susiebelle in reply to Robert185]

I hope the procedure is successful - I too had a stroke when I was 51 - I had been taken off warfarin because at a moment in time I was inNSR ( attending for a cardio version ) have been in warfarin for 4 years - not coming off it but watching the developments if NOAC and their antidotes.

[PeterWh]

Also don't forget that until you have had assessments (eg echocardiogram, etc) and had those tests assessed by a consultant you may not be aware of other problems, underlying issues, etc that can affect your score.