Paroxysmal Afib, ECGs, and As Needed NOACs

[netpi]

health.usnews.com/health-ca...

[PeterWh]

As the article says this is an "investigational pilot study" and was is only suitable for "a very select group of highly motivated patients".

One thing that the article did not address (that I highlighted in previous posts) is that some people have asymptomatic events particularly at night. 

[Mike11]

I think the only way to really make this work would be to wear a device 24/7 which monitored your heart and then injected the NOAC when needed.  In fact it could put a beta-blocker or whatever as well.

[Alan_G]

What I find interesting about this report is that it implies you are not at an increased stroke risk when you are in NSR. This contradicts that you need to be on anti-coags even if you are in an extended period of NSR.

[PeterWh in reply to Alan_G]

It is not a definitive report nor a definitive study. The answer to stroke risk is no one knows exactly since no significant or widespread studies have been done not current ones. The current belief of many is that patients are at an increase risk of stroke once you have had AF but are then in NSR. Is that 5 times?  No one can be sure. The high Probability is that it is not the same as Joe Bloggs (ie not 0% increase) but less than 500%). A further complication is that you would need to rerun loads of other studies because the chances are very high that if you excluded all the people with very few AF incidents then the 500% would increase!!!

On the other side there are medics who don't prescribe anticoagulants if in NSR because they believe the risk is not great.

[Alan_G in reply to PeterWh]

Fair points. Also statistics like '5 times' and 500% sound scary, but in reality it could be just turning a .1% risk into a .5% risk. Not so scary on the face of it.

[Alan_G]

Sign me up. I take my pulse at least twenty times a day!

[Bagrat]

I thought ( but could be wrong) that AF can cause physical changes to the heart which make it more likely for pooling or clotting to occur. I've only ever had 3 episodes of AF (fast AF of which I am aware) since 2011 but was happy to take anticoagulants on the advice of cardio consultant.

[PeterWh in reply to Bagrat]

That's what I understand. 

[MarkS]

I'm not sure this study is worth the paper it's written on. 

It says "These drugs [NOACs] work faster than warfarin and can apply to a broader pool of patients, including those with "non-valvular" atrial fibrillation." Well most people with AF have non-valvular AF and most of those are on warfarin. It's the much smaller group who have valvular AF who are actually recommended to take warfarin rather than NOACs, so arguably warfarin is recommended for a broader range of patients.

Also the study was woefully underpowered with only 100 patients. At the most there might have been one stroke without OACs making the results pretty meaningless. 

[Beancounter Volunteer]

This flies in the face of other studies which say due to the changes in the heart caused by AF, and the fact that it's entirely possible to be in AF and not know it (even between taking pulses) that the stroke risk is not lessened in paroxysmal sufferers.

Very small population in the study I noted.

And Alan yes 5 times 0.1% is only 0.5% but then that's 1% next year, 5% in ten years nearly (yes I know it's not a linear progression)

And all the time you are aging that 0.1% is getting higher, and therefore the 5 times is multiplying it higher still.

Be well

Ian

[dave205]

By taking Apixaban or other NOAC you increase your risk of having either a stroke or major bleeding with a Cha2ds2-vas score of 2 and a HAS_BLED score of 3.

                                                        No Therapy               Apixaban

Stroke risk                                         2.9%                             0.8%

Major Bleeding                                 0.6%                             3.9%

Stroke or major bleeding                3.5%                             4.7%

See the following link to get your scores:

sparctool.com/

[Bagrat in reply to dave205]

I'd rather have a major bleed than a stroke tho' I know I won't have the luxury of choosing. I think adding the two together to say you increase risk is very misleading as the out comes of the two possible events are very different

[PeterWh in reply to Bagrat]

I read that the numbers between the two calculations are not comparable.

[Thomps95 in reply to PeterWh]

One should never trivialize the risk of "major bleeds" as they are often fatal. Comparing hemorrhagic and ischemic strokes, hemorrhagic stroke has a higher mortality risk

Ferro JM. Update on cerebral haemorrhage. J Neurol. 2006; 253: 985–999.

Sacco RL, Wolf PA, Kannel, McNamara. Survival and recurrence following stroke. The Framingham Study. Stroke. 1982; 13: 290–295.

Bamford J, Dennis M, Sandercock P, Burn J, Warlow C. The frequency, causes and timing of death within 30 days of a first stroke: the Oxfordshire Community Stroke Project. J Neurol Neurosurg Psychiatry. 1990; 53: 824–829.

Anderson CS, Jamrozik KD, Broadhurst RJ, Stewart-Wynne EG. Predicting survival for 1 year among different subtypes of stroke. Results from the Perth Community Stroke Study. Stroke. 1994; 25: 1935–1944.

[timince]

I have paroxysmal AF with about one episode per month, always triggered by indigestion/wind. I am on dabigatran with a PIP of flecainide and bisoprolol which always brings me back to SR within 3 hours. I always know when I'm in AF ( usually preceded by strong ectopics) when I'm awake but a couple of times have woken at night in fast AF. I queried of my AF nurse practitioner why I needed to take anticoagulants every day when I had so few episodes of AF and could I not just take a dabigatran as soon as an episode starts? She replied that clots can form in the atrium within a few minutes and the dabigatran may not act quickly enough to prevent a stroke.

Luckily I have no known side effects from dabigatran so I am quite happy to go on taking it daily. However, apart from the cost to the NHS, I have no idea what the long-term effect it is having on my general health.

I would love to see more in-depth research into the possibilities of taking anticoagulants on an "as needed" or PIP basis.

Tim

[PeterWh in reply to timince]

How can you be 100% the other way round?

The report is a preliminary stage looking into that on a small scale basis (as it makes clear). However I suspect that the vast majority of small studies do not develop into larger studies. Furthermore there will be many large studies that end up not being conclusive or giving the expected / hoped for results. However as there is obviously publicity at this early stage there might be enough to do further more in depth studies. However that may take very many years. 

[Bagrat in reply to PeterWh]

I doubt they'll get any drug company funding!!  

[cat55 in reply to timince]

Hi Tim,me too, I have a huge problem with taking potent medication for something I have had once in the last three years. Less than 10 episodes in 14 years. here's hoping. Best wishes Kath