Anticoagulation

I was being seen by the nurse at my doctor's today and she said there had been a new directive for everyone with a chads score of 1 and above to be offered anticoagulation. Has anyone else heard of this?

I had an ablation just over 2 years ago and the AF episodes have come back so really want to be anticoagulated but always had too lower score, being only 55. I am seeing my EP in a month to hopefully have another ablation.

Thank you all for being there :)

36 Replies

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  • Not heard of this yet, but then I'm over (well over!) 65 and already anti-coagulated so I doubt it would be mentioned to me. Do you know who issued this directive?

    Hope your EP appointment results in ablation.

  • No I don't know and will ask my EP.

  • You will find that different countries will have slightly different recommendations. My understanding for U.K.

    If you have or have had AF:-

    0 = optional - fairly low risk

    1= recommended - that means if you are female you would score 1 without any other factors

    +2 = strongly recommended - as a 65 yr old female I went back on anti-coagulants aftern1 year off them after successful ablation.

  • I notice that some countries use different cut-off values depending on whether you are male or female (e.g., male = 1, female = 2)

  • I was given score of 2 for being over 65 and having AF

  • I haven't heard of this yet, I am 57, female, in UK and I scored 1 on the Chad Score, I wanted to be on anticoagulation drugs and had to stand my ground. I am on Riveroxiban.

  • My EP has had me anticoagulated for years with a score of 0. I have questioned him a few times about this but he has always ignored the score. My score is now 1 because I'm over 65.

    Koll

  • I am a 55 year old female in the UK so score 1 also. I will report back after my appointment on the 16 June :)

  • My husband got a letter from the surgery yesterday inviting him to discuss anticoagulation as he had previously had a slight heart ' wobble' and they thought he may benefit from medication. All out of the blue as his wobble was several years ago.

  • I am assuming that women are much more prone to strokes than men, hence scoring 1 for being a woman. We are also assuming that the fact that women tend to live longer and at some point (it was age 80 in the 1960s when I was studying demography) there are two women for every man has been added in.

  • For me, it's not about directives but evidence. There is research on the net benefit of anticoagulation for stroke risk depending on CHAD2VAS2 score. Unless the anticoagulant will reduce my stroke risk, I'm reluctant to take a powerful drug every day.

    I will consider anticoagulation when my CHAD2VAS2 score is 1. However, at the moment the evidence that it would help is slim.

    For example, in a 2015 Swedish study of 140,420 patients with AF, they found that men and women with a CHAD2VAS2 score of 1 had extremely low stroke risks -- 0.1 to 0.2% per year for women, and 0.5 - 0.7 for men.

    They concluded that the risk of ischemic stroke among patients with AF and a CHA2DS2-VASc score of 1 is lower than previously assumed, and their meta analysis of existing research to date suggests there may be "... unnecessary, and potentially harmful, OAC treatment of low-risk patients." In the authors' words, for these people (score of 1): "Treatment benefit is unlikely with warfarin or ... newer drugs (dabigatran, rivaroxaban, or apixaban)"

    Now, this is just one meta-analysis - so I'm not advocating that you say no if your doctor recommends anticoagulation! People need to do their own research, and evaluate the evidence for themselves in consultation with their cardiologist. Even in the absence of evidence, many feel it's better to be safe than sorry - and just to take anticoagulation - this is a rational decision too.

    sciencedirect.com/science/a...

  • when it is said that anticoagulation is potentially harmful, do we know in what way this is? I have always been lead to believe that the new drugs are quite safe ? If you have any more info that would be useful. Thanks

  • They were just talking about the HAS-BLED score - the risk of haemorrhage - the new drugs are apparently safer than warfarin, but any drug that inhibits coagulation is risky if you have an accident, especially if you suffer traumatic brain injury (e.g., from car accidents, being punched, falling, sports, cycling accidents etc). Traumatic brain injury is surprisingly common, so if you're on anticoagulation, you need to be careful.

    see mdcalc.com/has-bled-score-m...

  • We all need to bear in mind that very many older people die of a knock to the head followed by a haemorrhage within the skull. As we age, our brains shrink, and the space between the brain and the skull grows larger. The blood vessel walls will also be less elastic in older people. This shrinkage stretches the blood vessels connecting the lining of the skull to the brain, which supply the brain, and these can easily become damaged when you take even a slight blow to the head. What follows an intercranial bleed is not pleasant and will result in some brain damage due to increased pressure on the brain, as a minimum. Anti-coagulation has to balance this risk against the very real risk of a stoke which has equally serious consequences.

  • This is why the doctors will use both CHADs2VASC2 along with HASBLED to help assess risk : benefit.

  • @ Bridges4 - I had a series of bad side effects from 3 NOACs which showed that those drugs do not just carry the elevated risk of bleeding, but cause changes in your whole body (liver, kidneys f.ex.) . So, safe? They are much too new, too, to call them that. I am pretty sure that within the next ten years a lot more will be found out.

  • I also wonder with a study in one particular country whether or not diet plays a significant factor for health statistics. Let's face it the average U.K. Diet is not exactly healthy.

  • Yes I lived in Sweden for 6 month and they are pretty health conscious!

  • At the end of the day it is a personal choice to accept of refuse. For everybody like Thomps above you will find another who knows somebody of 50 something or younger with AF not on anticoagulation who had a life changing stroke. Sadly statistics don't work if you are one of the rare ones but how do you know?

    I frankly applaud the initiative as UK has one of the worst records for anticoagulating at risk patients in Europe and we could save many thousands of serious strokes if this were changed.

  • I agree Bob! But people also get strokes while on anticoagulants. I have a personal friend who has had three strokes while taking anticoagulation. Now, it would be foolish for me to conclude "anticoagulants must have *caused* her stroke: better avoid them!" ...right?...

    In the same way, pointing to a single individual under 50 who has a stroke and isn't taking anticoagulation is similarly meaningless, and we have no idea if anticoagulation would have helped that individual (he might be like my friend, and have a stroke anyway).

    A lot of people "believe" in anticoagulation, almost like a religion as an act of faith (we all previously "believed" in aspirin too). But we need to be smart about this, and consider actual evidence based on large samples. The study I quoted was based on 140 *thousand* people with AF.

    Don't get me wrong, I'm in favour of anticoagulation - I'll almost certainly be taking it within five years as a permanent medication. I just feel it's good to know what the scientific evidence tells us, so that our decision is well informed.

  • I would even say that some people find anticoagulation a comfort blanket. Not me, I'd like to be able to throw mine away.

    With other medication, i.e. for rhythm or rate control, they are acting on the heart itself. Anticoagulation makes no contribution at all to relieving AF. If the rhythm or rate control drugs were doing their job, or indeed if someone has had a successful ablation, the threat of stroke should be sufficiently diminished to make anticoagulation unnecessary.

    What we really seem to be saying is that none of the treatments for AF are much good at reducing stroke risk.

  • Agreed: AF is a "marker" for stroke, so the traditional explanation for a link between AF and stroke (blood pooling etc) is gradually being replaced with a more complex understanding of this connection that considers co-morbidities and abnormalities that gave rise to the AF in the first place. Some research now suggests that eliminating episodes of AF (whether through ablation or drugs) won't *necessarily* lead to a reduction in stroke risk - especially if there are significant co-morbidities

  • I asked to be put on anticoagulation at 56 because my cousin, who has the same thing, had a series of TIAs at 57. When you have this close to you, it does help to make up your mind.

  • Currently anticoagulation in the UK is not offered where a chads2vasc for women is 1 where that score is for sex alone, this is because below 65 the fact that you are female does not statistically increase your risk. I have currently seen 4 cardiologist (I have asked to see an EP but no luck just sent for a fourth cardiologist appt) 2 have referred to the chads2vasc score so no anticoagulant and 2 have said that because my afib is paroxysmal the chads2vasc score isn't valid as it's only for people with permanent afib as paroxysmal afib carries much higher stroke risk and everybody should be on anticoagulants. So whose advice should I take? I can't find any evidence to back the latter two doctors only five recent trials that state the opposite. At the end of the day as a country we will only cut the amount of strokes if anticoagulation is given to people at greater risk it won't help at all giving it to people where their risk of stroke is less than their risk of bleeds just move the problem elsewhere!

  • Interesting!

  • Talk to any EP that I know and they would not say this! Scoring 1 and having had a successful ablation my EP recommended AC but when I hit 65?he insisted.

    I have not had good experiences with cardiologists and AF.

  • one thing which may help people decide about anti coagulation- if their chads vasc score warrants it, is what a stroke consultant told us at a meeting of our ;local CCG who are re-organising stroke services.

    I had been stressing the importance of the work we are doing( our support group) to let people know about anti coagulation when they have AF. One of the nurses present said,." AF isn't the only cause of stroke," to which I answered. "Yes but AF strokes are much more debilitating so effort here is worthwhile"

    At this point the Stroke consultant joined the conservation to say,' Out of the last 9 deaths we have had from stroke, 6 were AF patients, and AF strokes, if survived, leave people much more damaged than other strokes."

    Very relevant when we make decisions I think.

    I asked once why age makes a difference and the answer given was that the tissue surfaces change as we get older- ( like getting wrinkles I imagine

    therefore although being 65 is the cut off point one might want to consider this at ages near the cut off point?????

  • PS to my post- and take HASBLED score into account for bleeding risk

  • Just a thought here on HASBLED. I was told a while back by a leading consultant that HASBLED was not a score system to judge bleed risk but an aide memoir of things to consider and hopefully deal with/treat before assessing CHADSVASC. It is not so much balance one against the other as dealing with the bleed risk elements.

  • Interesting replies and I am sure they helped, but I don't think that you should wait to find out if you need them after the event. You could do your own research on various new drugs available. If you are concerned that you could hemorrhage, which is a possibility, you might consider Eliquis apixaban 5mg morning and night, so as not to overload at one time which eventually I did.

    You also need to think about what other factors your doctors might have considered regardless of the chad score, but really the decision is up to you since you are only 55 with a chad score of 1. Your diet might help with this while you are waiting for your next appointment and before you decide.

  • Thank you all for your replies and I will report back after seeing my EP in June :)

  • I've never heard of a chad's score. Is it something I should know about? I was 53 when I first had a major attack of PAF ,was admitted into resuss and kept in hospital overnight. I'm coming up to 71 so take heart. all the best

    Annlynne

  • Are you on anticoagulants?

  • just another point. I was prescribed Clopidogral and tried myself to avoid Warfarin.(don't ask me why, just always listen to the professionals) I eventually agreed to taking Warfarin and was due to start taking it beginning of May 2009 Last two weeks of April we flew to the Canaries. How I wish I had already started on the Warfarin as I had a massive stroke a couple of days after we returned home. I really don't want to upset you Kiwi2 but I was only 63 years. Good news is : I survived thanks to the skill of dedicated doctors and advances in medicine. Just take your consultant's advice , that's all you can do.

    very best of luck, take care

    Annlynne

  • My score is 2. Female and previous TIA

  • I am female 60 and had TIA and my score is 3 with no other risk factors. Not that it makes any difference to anticoahulation as both scores indicate anicoags. X

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