upcoming ablation. Query?

[cali111]

I have just been to see my cardiologist and he is requesting that I be changed from Apixiban over to Warfarin for the procedure on the 26 September. When I queried this he said the EP had requested it. Anyone know why?

[Rellim296]

He is out of date. You can have an ablation when you are on a NOAC.

Would you really be able to have an INR in range for a month by 26 September?

[cali111 in reply to Rellim296]

I don't know the answer to the last question. He has a very good reputation, maybe he wants to check my NSR levels whilst I am Warfarin, which you can't do on Apixaban. I did question the Cardiologist on if the levels would be enough and he said he thought they would, so I have to go with the `experts`

[Rellim296 in reply to cali111]

Two and a half years ago it took me three months to get four consecutive INRs in range. My EP is now happy with Rivaroxaban which I had switched to by my most recent ablation. I just missed it out on the morning of the procedure, but started it again in the evening.

[cali111 in reply to Rellim296]

Further to my previous post I now have found out that the request was made to my GP last June and got `lost` I have spoken to the cardiology and they have said they thought I would be settled by 21st September. They was not pleased when they found out that their request in June was not actioned. I am now waiting for a call from the anticoagulation clinic to see what level of warfarin I have to take, but as it is now bank holiday I do not expect to have this before Tuesday next. What a mess!!

[Rellim296 in reply to cali111]

Three possibilities:

1. Insist you stay on Apixaban and hope they'll agree,

2. Switch to Warfarin, hope you'll be OK and all will be fine,

3. Switch to Warfarin, hope you'll be OK and you will have to postpone.

Option 2 is probably the best, though might be optimistic! Yes, what a mess - and not your fault.

As I had trouble with stability on warfarin, if it happened to me I'd be making a private appointment with the EP and pleading for option 1, although my EP is now happy with ablation patients on Rivaroxaban. If you've been on warfarin before and were stable you could go right away to your old dose and you might be OK.

[BobD Volunteer]

I'm with Rellim on this one. Modern thinking is even not to stop the anticoagulation prior to the procedure. I suggest you call the EP's secretary and point out that you doubt you will have time to get your INR stable and why anyway since NOACs are OK.

[cali111]

I will do this, thanks!

[PeterWh]

When I had my cardioversion 21 months ago I was on Apixaban. Then for the ablation EP did request at that time I be switched to Warfarin because at that time hospital insisted on Warfarin. However in the intermediate time they, and many other hospitals and EPs have switched to allow one of the NOACs but there are still some who insist on Warfarin. I elected to "transfer" earlier rather than sooner which is just as well because I was one of the unlucky owns (less than 1%) who have problems stabilising on Warfarin quickly.

Also check the INR range - this is very important. Most have the range as 2.0 to 3.0 BUT if you are in persistent AF they often set the range as 2.5 to 3.5 to allow for the fact that they often have to do a cardioversion at the end. Also some places and some EPs choose the higher range anyway because of the way the INR program calculates dosages - it waits until you are out of range before it adjusts dose but some clinics manually change if they see it continually dropping. This is so that you don't drop below 2.0 which is key for the procedure.

Also check the number of readings - this is very important. There are two ways of doing this. Many do it that it is 4 consecutive weekly tests that must be in range (ie this is over a 3 week period). However a few do insist on 4 consecutive weeks in range which is then 5 tests.

In reality it takes between 4 days and 2 weeks to get in range the first time - for me it was 4 days) 1st test Monday am 1st warfarin Monday evening then Friday morning I was in range. I reality that was only because I am at the low end of the scale and need small doses of warfarin (which is why they don't over do it). Normally it is at least 1 week to 10 days.

The above two reasons mean that it is very tight to me in range by 26 Sep as that is only 31 days away!!!

You didn't mention stopping anticoagulation so although I am guessing they are intending that you take it straight through please check.

[cali111 in reply to PeterWh]

Thank you. I am still trying to sort this through but the ep secretary says they like warfrin as the newer ones are difficult to measure. I am still trying to get confirmation that i will be ok for levels given the time frame and have been advised to ask my GP. No one is willing to comment. The hospital says the instruction for the change went out on June. So i am now really comfused.

[PeterWh in reply to cali111]

Still pursue it with them but it is looking like you will have to be swapped. Check their requirements re range and number of tests!!! Worthwhile pointing out that time is not on your side!!!

In the meantime phone up GP's surgery to find out where you are whether it is the local anticoagulation service run by the CCG who do the warfarin clinic or it is the GP surgery (round here it is the CCG). Book yourself an appointment for Monday. With Apixaban there is an overlap so you continue taking Apixaban as normal until your INR is up in range.

Just as some comfort in MY case I did not have four consecutive readings in range because of my partial intolerance to warfarin and actually on the day of the ablation INR was only 2.2 and not in the range 2.5 to 3.5 that EP wanted. He did not mind and still went ahead because he gave me heparin to give the necessary "boost" and in any event he was doing a TOE at the beginning of the procedure.

[Rellim296 in reply to cali111]

It's bad luck you have this to battle with and time not on your side!

The thing with warfarin is that INR wanders! Some people take to it like duck to water but there's no telling if you will have it under control in time.

NOACs taken regularly provide much more constant protection so they don't need measuring - this seems to be so hard for some brains to absorb.

[cali111]

I have found out that the hospital made the change request in June but the surgery didnot implement it. The hospital is not happy and the surgery is getting a perscription today. They have not yet heard the last from me

[MarkS]

You will need regular INR tests - I suggest twice a week. Some surgeons prefer warfarin as it has been proved to be fine without interrupting for the ablation.

That is the critical issue - whatever anti-coag you're on, it must not be interrupted for the ablation. Ablations can produce lost of micro-emboli - basically small clots. Generally they don't affect you at the time but they can have long term effects on, for instance, memory. Anti-coags really reduce the number of these but it must not be interrupted. That applies equally to warfarin and the NOACs. Warfarin has the advantage that it can be tested, so as long as you're in range (2-3.5) on the morning of the ablation then you're protected.

I've seen some posts where people have remained on NOACs then interrupted on the morning of the ablation. That does not provide protection. Those EPs really do need to read and understand the latest research.