Advice about the newer anticoagulation drugs

[Nickibmibile]

I have had a heart "problem" since the age of 15 and I am now 49. I had my Mitral Valve replaced 34 years ago and then again 13 years ago when it failed. For 21 years I took Warfarin so am well aware of the pitfalls and the benefits of this drug. Three years ago I began to suffer with a very low heart rate and all the associated problems one being I fainted on the loo and knocked myself out, not very dignified! My cardiologist decided I needed a pacemaker which I have. My heart is damaged and I've had an irregular heart beat for more than 30 years but as it was a regular irregular heart beat my Cardiologist said he was happy with it, however, two months ago I started getting palpitations and felt like my heart was racing. The Pacing Clinic altered my pacemaker and it seemed to resolve itself but my Cardiologist said if the issues continued then I would have to have Cardioversion, I wasn't happy with that so he started me on Beta-blockers. I've had another Cardio appointment, ECG etc and I'm in AF, and it turns out that I have been for quite some time, so the time has come for further treatment. I really want to avoid the Cardioversion if I possibly can so I've been told anticoagulation is the only other option open to me. My question is how successful, reliable, "good" are the newer anticoagulation drugs? I welcome everyone's opinion good or bad, I feel rather nervous about them. Thank you for taking the time to read my post. Nicki

[Mazza23]

I have been on Apixaban for 2years no prob no need to worry about CV if it puts you back in NSR it's great I have had 7 of them people on here have had more

[Scorer]

Have been on rivaroxiban for two years now without any problems. I was fortunate to have a successful ablation for A fib & flutter with no recurrence. Hope you get this additional problem sorted. Best wishes.

Pam

[BobD Volunteer]

Whilst I do not really understand your reluctance to have a cardioversion I wont go there right now. Regarding NOACs there is some evidence that they are more effective in stroke prevention than warfarin where patients have a poor record of INR control. Some of them also have slightly lower risk of intercranial bleeding from what I have read.

Personally since I have a good record over the last eleven years I see no reason to change but any worries I had when these drugs first came along have long since been quelled. Many people worry about lack of reversal agent but this is a red herring in most cases since there are ways to deal with any accidental bleed and the much touted Vit K route for warfarin is far from instant in any case.

[jennydog]

I have been taking Pradaxa ( dabigatran ) for over 2 years. No problems except for not originally realising that it needs an acid stomach, so no antacids. It has an antidote called Praxbind. Dr Gupta covered NOACs in a video recently and I thought that he was keen on dabigatran.

[CDreamer]

Most NOACs - I think there are now 5 or even 6 of them now - have been in general use for quite a few years now and in my opinion have quite a few advantages over Wafarin and are MUCH less hassle to take and very effective.

I took Dabigatran for about 3-4 years. Since ablation no AF and no need to take anticoagulant, some people continue to take for life and will disagree with me.

1. They work differently to Wafarin so do not have INR testing.

2. That means you don't have to worry INR going out of range if you have difficulty stabilising.

3. Travel - no loading for travel insurance.

4. Some trials have shown that there are fewer brain bleeds with NOACs compared with Wafarin.

5. You only need to take 1 tablet either every 12 hours or with some X1 day.

6. What you drink and eat has no affect on INR.

7 they have a very short half life, which means they clear your system very quickly, unlike Wafarin which can take a days.

Cons -

if you like to be reassured by INR test results you won't see the evidence that they are working.

Unlike Wafarin which has antidote Kit K, most do not have an antidote and some people worry about that. That is not an issue as far as I am concerned as there are procedures to counter affects in medical emergency and because of short half life it clears your system quickly.

Some people need to be careful with how and when they take NOA. As they can cause gastro problems such as heartburn - easily rectified as long as you DON'T take ant-acids or the PPIs GPs tend to prescribe.

Why would you want to avoid cardio version? It may put you back into NSR.

Do not allow fear to rule your life, you need to rule your fears.

[PeterWh in reply to CDreamer]

Mainly for Niki's benefit but vitamin k can be quite slow in reacting - in my case it took 26 hours to get the INR down.

[JayDW in reply to CDreamer]

I am recently diagnosed and have been on Pradaxa for about two months now. I had a period when I was getting excruciating heartburn, but I discovered that taking much more water with it solved the problem - at least a full glass.

I was not aware of the ban on antacids, so thank you for that.

[CDreamer in reply to JayDW]

It wasn't a ban it was just that I found I had dreadful heartburn and then I discovered why - I was taking with carbs - carbs tend to change the Ph of the stomach to slight alkaline state, this means the stomach contents don't empty - where does the acid go - straight back up the esophagus causing heartburn. What do antacids or PPI's do - make it worse.

The gel capsule containing Dabigatron requires an acid stomach for it to dissolve, therefore ant acids tend to help the discomfort but also hinder the absorption processing.

The glass of water is also a requirement but that was stated in the leaflet in my pack, the requirement for acidity content of the stomach wasn't but it is in the trial data of some of the researchers.

Best mix I found was take with either yogurt, fruit or protein and large glass of water and never take last thing at night! Which Hubbie often does and then wakes me for an antiacid.....but then what do I know? LOL

[Rellim296]

I've taken Rivaroxaban for over a year and find it problem free. I was scared stiff when I started taking warfarin three years ago, convinced for a short time that some fatal haemorrhage would carry me off and I had only weeks - or days - to live.

Much is said about the lack of antidote with the new drugs, but it may not be as significant as it might sound. Vitamin K takes hours or days to work and life threatening bleeding can kill anyone if bad enough, be they on Warfarin, a new anticoagulant or nothing at all. There's just a different point for those on anticoagulation where bleeding may be serious enough to be uncontrollable.

[scotcitz in reply to Rellim296]

Thanks for this message. I just started on Rivaroxaban and had the same feelings as you -- been on it for about 3 weeks now and frankly I seem to bruise less than when I was on aspirin (I was like a peach ... ) So it doesn't mean you shouldn't be careful etc but certainly seems OK so really good to hear that you're still great after a year on it and you also went through a period of fear with it. I think doctors really don't acknowledge that it's scary. My Mum (who had afib) took warfarin and just happened to be a person who had an INR all over the place although she tried her best with diet, etc., and she did have several strokes (none of which gave her serious disabilities but which in end added up to some dementia for her in the end). So here's hoping that Rivaroxaban does a better job ...

[Rellim296 in reply to scotcitz]

I think the new anticoagulants may do a better job. INR checks are fine when the result is good but no fun at all if INR is always going all over the place.

[MisUse]

I am on warfarin and looked at changing to one of the newer ones, however I have a leaky aortic valve, and have been told that any valvular issues you cannot take the newer ones so I seem to be stuck on Warfarin. If you find out about one you can take even though you have had valve replacement please let me know

[MarkS]

I'm not sure you'll be able to use an NOAC as you have an artificial valve. Presumably you have a Coaguchek monitor so you can check your INR? If you get good INR control, then warfarin is at least as good as NOACs, which do not have the capability of being measured.

On another point, there is a lot of misinformation on warfarin reversal. Vit K is only used to reverse warfarin in a non-emergency situation. In an emergency it is reversed with PCC in about 10 minutes. Praxbind for dabigatran is equally effective, but at £2,400 per shot I understand it is only stocked in a few places and not generally available. PCC is stocked in all hospitals and is even carried in air ambulances.

[PeterWh in reply to MarkS]

Mark. That's interesting about PCC. When I was admitted to A&E with a suspected bleed in the brain or stroke they gave me vitamin k to reverse so that they could do a lumbar puncture. In the event it took 36 hours to get the INR down enough.

[seasider18]

Do you have a mechanical or a tissue valve ? You cannot take NOAC's with a mechanical valve. The jury is still out on the safety of NOAC's with tissue valves. Cardiologists will prescribe them but makers say that they are contra indicated.

Why are you against having a cardioversion?

[Nickibmibile in reply to seasider18]

My valve is biomechanical and both my cardiologist at the hospital and my GP have discussed the NOAC's with me so I hope I am correct in assuming my valve is compatible. My previous valve was mechanical and I was on Warfarin for the 21 years I had it installed. Since then, with my new super duper valve, I've only taken Aspirin on my cardiologists authority and not for anticoagulation properties.

Part of my fear of cardioversion is having another general anesthetic, I want to avoid it if possible.

Thank you for your reply x

[Dayu]

Hi Nicki, I was also quite nervous about taking anticoagulation drugs but my Cardiologist suggested a new drug called Rivaroxaban 20 mg...and so far so good

[Nickibmibile in reply to Dayu]

Thank you for your reply, I'm glad you are doing well

[Annaelizabeth]

Really interesting post, as we are moving into the realms of those with artificial valves and af. At the age of 15 was your mitral valve replaced with an artificial or tissue valve? I am assuming that, at your young age, it was artificial (St. Jude?) as a tissue has a life expectancy of about 10 years whereas artificial is supposedly a lifetime, and replacement is not a route either surgeon or patient wants to go down. Hence warfarin would be your anticoagulant. Move on through your second replacement to pacemaker. Was there no time that a pace and ablate was suggested?

I have had an artificial valve for over 20 years with continuos warfarin. Using the newer anticoags is not an option as they have not been approved for prosthetic valves. During that time I have had 3 ablations and 2 cardioversions, and finally seem to be arriving at a point of af peace - tempting fate by saying that!

Don't be put off by cardioversion if it is a viable option, you can ask to know nothing about it - and you won't!

In the meantime, I hope what ever you choose goes well for you.

Anna

[Nickibmibile in reply to Annaelizabeth]

Annaelizabeth thank you for your comment. My first valve was a mechanical one, I remember the surgeon telling me it was teflon and indestructible!! I don't think it really was teflon and it certainly wasn't indestructible for me but nevertheless he put my mind at ease and the valve worked perfectly for 21 years which I think is pretty good going. I added complications for myself by wanting children and as you may know warfarin doesn't sit well with pregnancy so I had intravenous heparin via a central line (hickman line) in my chest for my first three pregnancies (two unsuccessful and the other gave me my daughter). The following five pregnancies I gave myself daily injections with low-molecular weight heparin (the joys). My son,Daniel, was stillborn at 24 weeks and my second son, Matthew, was delivered permanently sleeping during my second mitral valve replacement surgery. I gained a brand new bio-mechanical valve from the surgery but lost my son and my ability to have any more children. I haven't taken any form of anticoagulation since then however my cardiologist (who I have know since I was 20) prescribed 150mg aspirin to make my blood less "sticky" and possibly as reassurance for me as I was convinced my blood would be too "thick" without the warfarin.

An ablation has never been suggested to me just cardioversion and anticoagulation. My irregular heartbeat has been on going for a number of years and the AF a frequent visitor and usually I don't even know it is happening. It is only since having the pacemaker fitted that there has been a record of the AF. I know that my trace doesn't show a "P" wave despite having this explained to me I really don't understand fully what this means. I've been told the the pacemaker will "pace" if my heart doesn't beat properly and basically prevent my heart from stopping, that sounds good to me

[Nickibmibile]

I am on Warfarin again. My GP and I decided that having INR checks would be a good thing. So far I'm only on 3mg and I'm totally ok, I may have to increase it to the 8 - 10mg I was on previously but we're going slowly.

I would like to thank everyone for their help and support, thank you xx