Conflicting doctors advice

Hi...

My EP nurse says I should be on Eliquis for the rest of my life to be on the safe side. My cardiologist says after your abalations have been successful for a certain amount of time you should get off it because of the risk of internal bleeding...what to do when two very good doctors have opposing views. My regular doctor says you shouldn't stay on Eliquis forever. What do you think?

25 Replies

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  • My cardio and EP says I will be on it for the rest of my life because even after ablation AF can happen again I would also choose to stay on it rather than risk a stroke

  • Doctors like to be cautious. Why not just look at the original scientific evidence? It entirely depends on your other risk factors - if you have no other risk factors then there is no evidence that you need anticoagulation (after the ablation settles) and no evidence that you'll actually benefit (identical stroke risk for those taking or not taking anticoagulation). If you do have other risk factors then it may be of benefit so might be sensible. Best to look at the research.

  • Eliquis (Apixaban) is still comparatively new so how either of them can make such far reaching judgements is beyond me. I've had two ablations In the last 2 years and have been on Apixaban for the same time, I'm seeing my ,EP in May and although my AF has behaved itself for 6 months I wouldn't want him to withdraw it unless and if there is suddenly good clinical reasons for it. The biggest problem arises from surgical and other intrusive procedures when there is usually varied advice about how long one should be off it.

    My view is the EP is probably the best source of advice, I've recently had a biopsy and a tooth removed with no great issues and am due an inguinal hernia repair in May,

    i take it and don't worry about it - the possibility of a stroke if I don't does!

    Hope that helps - we 'll all know more down the years ahead.

  • I think this is an area where knowledge and practice is developing continuously. There is some evidence that it isn't AF per se that causes strokes but, the suggestion is, that it is related to the co-morbidities that come along with AF that cause strokes. This runs counter to the argument that strokes are caused by blood pooling in the AF-affected heart, clotting and causing strokes - which seems as if it might be a convenient causal chain though substantially incorrect.

    I am certainly not in a position to determine which theory is correct as I am not medically qualified but it seems to me that it is wise to continue with anti-coagulation while there is a stroke risk. If the stroke risk has gone, then anti-coagulation can be stopped. CHADSVASC is a bit of a blunt tool to establish stroke risk (except it seems to work).

    I think it's a case of "you pays your money and takes your choice". I'd say that if anti-coagulation isn't causing you major difficulties, continue with it. If it is causing you major difficulties then you could consider stopping it in the right circumstances - and those circumstances may change over time.

  • I think the 'blood pooling' gives your blood the opportunity to clot because it is still. I believe you need the comorbidities to make this more likely to happen. Having still blood in your body is like an invitation to clotting.

  • Here is another theory that it all depends on how your LAA contracts. If it could be checked to see if it contracted properly you could do without the drugs.

    In some patients with A-fib, the LAA does not contract effectively and it can become a source of blood clots. These clots can then be released into the heart and enter the bloodstream, where they can travel to the brain and cause a stroke. Currently, patients with A-fib are often prescribed blood-thinning medication, but this treatment option comes with a lifetime of medical management and the risk of major bleeding.

  • What is LAA?

  • Left Atrial Appendage:

    The left atrial appendage (LAA) is a small, ear-shaped sac in the muscle wall of the left atrium (top left chamber of the heart). It is unclear what function, if any, the LAA performs.

    In normal hearts, the heart contracts with each heartbeat, and the blood in the left atrium and LAA is squeezed out of the left atrium into the left ventricle (bottom left chamber of the heart).

    When a patient has atrial fibrillation, the electrical impulses that control the heartbeat do not travel in an orderly fashion through the heart. Instead, many impulses begin at the same time and spread through the atria. The fast and chaotic impulses do not give the atria time to contract and/or effectively squeeze blood into the ventricles. Because the LAA is a little pouch, blood collects there and can form clots in the LAA and atria. When blood clots are pumped out of the heart, they can cause a stroke. People with atrial fibrillation are 5 to 7 times more likely to have a stroke than the general population

  • Thank you.

  • Hi

    Obviously you must do lots of research as suggested below, but after my ablation for PAF with cryoablation, my EP took me off the blood thinner he put me on for the procedure and a month only afterwards as no other physical problems. He , (and my GP agreed when I asked her about it) took me off it as I am only 59(just!) and risks of taking it now out weigh advantages according to them. (They may well advise me to take one as I get older and if AF symptoms return.)

    My EP nurse at the time, often gave me conflicting advise about things while in recovery mode and when I phoned after 6 months to ask for some advise, she had moved onto another heart dept so personally I would listen only to the main EP as she/he is constantly there doing ablations regularly seeing lots of different people with AF and associated symptoms and medical and family history. GP's are helpful but not usually experts in ❤️'S!

    Hope you find good help and advise on this issue as I believe it to be a difficult decision to make as we all want to stay well in the future.

    With good wishes

    Sarah

  • There is currently no evidence to suggest that successful ablation removes any stroke risk which may have existed prior to that ablation. In fact the process of ablation may cause changes to the internal surfaces of the heart which may promote clot formation. Many EPs believe that continued anticoagulation is worthwhile. Another thing to consider is that ablation is not a cast iron cure for AF which may and sadly often does return eventually.

    One leading UK EP has suggested that it is not AF which creates the risk but the company it keeps.

    My view is that if you had a CHADSVASC score of 0 and only went onto the anticoagulation for the ablation then it might be safe to stop but it is all about risk acceptance and QOL. If taking anticoagulants has no effect on your QOL then it may be a more difficult choice to make but I know that for some unfortunate people these drugs are a problem and they can't wait to get off them.

  • What is QOL?

  • Quality of life

  • Hi

    You need to research and research and think what your body needs

    But bare in mind some research can be biased or not correct its easy done in the health field 😳

    Its hard i know

    Dont forget many doctors are not sure really what works and what doesnt work for afib

    Its still all theories and trials and errors

    So u need to decide for your self 🌺

  • Thanks for posting this. I feel I am in a minefield at the moment - how do you know what is a good, truthful, research paper? I see this week that the House of Commons is looking at the way research is /or not carried out in our top Universities. Apparently not all of the research is carried out as well as it should be. Fake news is everywhere!!

  • Hi

    Yes difficult

    Mmm

    I don't always look at "resesrch papers" because i know what they do

    For that reasons i go with common sense

    Research around ablations what are the real risks etc do i really need an ablation or is it a short fix and make the problem worse at a later date

    not sure but these are things i think about

    I have PAF and i have aggressively changed my life for the better i try and research foods herbs ways that make my body healthier

    It takes time for body chemistry to change after abusing it its not a quick fix

    Not sure what i would do if i have persistent af

    It is a headachge cause as i said before the health professional dont even know themselves why Afib happens in most cases

    I wish u well in your journey 🌺

  • Thank you for your answer. My problem at the moment is with Apixaban. I was given Prasugrel some years ago after a heart attack - no information was given to me by the hospital. On returning home my upper legs were covered in a pin point rash. I reported this to the hospital and they were not overly concerned. However it was the weekend and I spoke with an out of hours Dr - He said he had been to lectures on it and would not give it to any of his patients. At 11pm I was telephoned by a Dr. from the hospital who was very angry I had been told this. I was able to see my GP on the Monday who immediately gave me a thorough check and filled out report form on the drug. Never taken it since. Hence my concern about being prescribed Apixaban. When you start looking - a lot of questions come up. Seeing my cardiologist tomorrow hopefully he can calm my fears. Like you feel I must listen to my body on this one. My husband, thankfully agrees.

  • A perennial - should I : shouldn't I question? No easy answer.

    Been there done that 3 times. It really depends upon what you chose and whether your EP is happy for you not to take it and that depends upon your CHADS SCORE / HASBLED score so check those.

    I came off anticoagulant after ablation, after I had no episodes for several months - I monitor myself regularly which my EP knows - and I am symptomatic so know when I am in AF.

    I was ok until I DID have AF episode and then I surprised myself just how worried I became because I wasn't on anti-coagulation and got a script ASAP!

  • It's not complicated. Yes, it probably is - but let's try and keep it simple. The second (some stats say third) biggest killer of mankind globally is stroke. Because untreated AF can increase our risk of stroke, we all know that anti-coagulation is recommended. As a result, affibers taking ACs are probably at lesser risk of stroke than their peers without AF who are not so treated. Of course if you have AF and are not on ACs....what can I say?

    I had AF, until a successful ablation 2 years ago, and the apixaban I take inhibits clotting. Why would I want to throw away that distinct advantage I have over most of mankind? Particularly as I am the wrong side of 60 and entering that 'age of man' when most strokes strike. I'll stick with the NOAC thanks, at least until I pass 80 when, it seems, life threatening bleeds may begin to outweigh the anti-clotting benefits.

  • drugs.com/eliquis.html

    Tells you all about it.

    I have had 3 ablations and 9 Cardio versions but I am one of the unlucky ones that it keeps popping back so I will be on blood thinners of some sort for the rest of my life. I do have other conditons that do not help any of this so not the norm in any way?

    Be Well

  • I looked at your history here to see how old you are? and I see you have had lots of health problems and unsuccessful AF treatments. If I were you I would feel safer on an anticoagulant if there is no contraindication.

  • I had an ablation a little over two months ago. When I went in to see the doc for follow up this past Monday he told me he had never seen such a quiet EKG (wore a heart monitor for 5 weeks) post ablation. I get a couple of PACs here and there, but he told me he was not worried about that. So inevitably the question came up about if/when I could stop Pradaxa. I was expecting him to say 6months, a year, never? He told me I could stop it right now. Needless to say I was shocked, and he saw the look on my face. He said "you seem surprised". I most certainly was. He said at this point the heart is healed and since I feel everything, plus I have the AliveCor to monitor, that he feels very comfortable to have me stop Pradaxa. So this runs conversely to everything I've read in this forum. I asked about the geography of the heart changing post ablation and how the blood may pool or eddy in the atrium from the scarring and he doesn't believe that's so. He said there are no divots that are formed from an ablation, so that wouldn't happen. He feels that I could stop it, with the understanding that if I feel any afib that lasts at least an hour, to take a dose of Pradaxa and call him right away. My background...60 years old, diagnosed with PAfib May of 2016, but had runs of afib every few months since the September before. My ablation was in February, so I got to it early. I told him I wasn't quite ready to stop Pradaxa; that it makes me feel a little nervous. He was fine with that...he wants me to stop it when I feel comfortable enough to but that he is very comfortable with me stopping now. He told me I can wait til our next visit (end of July) if that made me feel better. I think I might do that, as my regular doctor told me at his hospital the protocol is stopping after 6 months if there are no afib events. I ttrust my doctor but I'm too insecure at this point to stop. My EP is vey well regarded in the States and the hospital is one of the best for ablations. So I'm in a conundrum of sorts as well...

  • I am 4 months post ablation and have had no AF. Before the procedure my EP told me I could get off Eliquis after 3 months if all went well. At my 3 month check-up, the EP nurse told me the CHA₂DS₂VASc score guidelines included being a woman as a risk factor. Now, I have a score of 2 since I have high BP. I decided I'd rather be on low dose aspirin than risk taking a new medication long term. It is also expensive! Neither my cardiologist or GP thought it was necessary to stay on the Eliquis.

  • Yes, your GPs budgets are probably tight so why shouldn't you, for his benefit, take a chance with your life? Why not save him a few pennies more by stopping the aspirin too because that's doing absolutely nothing for your stroke risk.

  • But plenty for your bleed risk!

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