Anticoagulation and ablation

[F-M-C-MM]

I have noted from several posts that one must take Anticoagulation medication post Ablation for several months. However, can one come off them permanently if the ablation is deemed to be a success and all arrhythmia have stopped. I have noted mixed views on this particularly for those over 65? Not every EP seems to hold the same opinion. What is the general consensus?

[rosyG]

if you are over 65 I would be very careful!

I have been fortunate not to have had any AF for 3 years after adding more potassium rich food to my diet ( after noticing my level was below range in A and E)

I then had a two hour episode , vigorous, last night, and was so pleased that I take Apixaban. Apixaban has not caused any problems and you don't have the inconvenience with the NOACS/DOACS !!

[BobD Volunteer]

The people I trust generally agree that there is no evidence to suggest that successful ablation removes stroke risk. In fact is has been suggested that it is not the AF which produces the risk but the company it keeps ie CHADSVASC so for a person with a CHADS2VASC score of zero then a ) they would not be on anticoagulants other than for the ablation so b) would not need them afterwards, Any score above zero then whilst optional I personally would not stop.

Remember also that a score once given can not be removed so even if say you had controlled high blood pressure even though it is no longer high you still count that score.

[F-M-C-MM in reply to BobD]

I appreciate what you are saying about risk, and it's always better to be sure than sorry after the event but if there are certain factors present like a good family history, and an absence of any other underlying cardiovascular risk or other illnesses such as diabetes etc. Would physicians consider postponing anti coagulation once the A Fib is no longer a problem. Have you come across any evidence to support this argument Bob other than the CHAD VASC SCO?

[BobD Volunteer in reply to F-M-C-MM]

As I said above, if your score is zero before ablation then it is zero after ablation and the only reason you would have been anticoagulated would have been for the purpose and period of ablation/recovery.

Family history is of no concern in any of this. I wish it were knowing none of the males in my family for three generations before me have died before age 90+. Chadsvasc includes such as cardiovasculatr disease and diabetes , ( the C and D ) so if as you suggest there is no other underlying condition then with a score of zero read above.

The problem in all of this is that there will always be exceptions such as people with a CHADSVASC of 0 who have life changing strokes due to AF and not being anticoagulated just as there are bound to be one or two who suffer serious bleeds due to anticoagulation so one can only really look at the average "man on the Clapham omnibus. "

Just to repeat the gist of my argument, if you have no co-morbidites (CHADSVASC 0 ) and the only reason you were put on anticoagulants was for the ablation/ recovery period then I don't think that there is any argument to continue anticoagulation after a successful ablation . If on the other hand you had a Chadvasc score of 2 then you still do and I for one would continue.

[F-M-C-MM in reply to BobD]

Thanks Bob very clear explanation, I appreciate your very comprehensive reply. I didn't fully understand how the Chad Vasc score works.

[seasider18 in reply to BobD]

I used to live and work in Clapham but " the average "man on the Clapham omnibus " no longer exists due to population changes

.

[Thomps95 in reply to F-M-C-MM]

Factors not considered in the CHAD2VAS2 score are also relevant to stroke risk. The CHAD2VAS2 score incorporates the "big" predictors of stroke but it doesn't include all relevant factors, such as exercise, diet, whether you're taking proton pump inhibitors, how much alcohol you drink, your socio-economic status, whether you have a sedentary lifestyle, and so on (all significantly associated with stroke risk). CHAD2VAS2 is a great instrument and best follow the recommendations, but certainly, many other variables are related to stroke risk, so we should all attend to them carefully in addition to our CHAD2VAS2 score.

[Angie06 in reply to Thomps95]

I see you've mentioned proton pump inhibitors, are these likely to affect your Chad score?

[Thomps95 in reply to Angie06]

Taking proton pump inhibitors is associated with slightly increased stroke risk. See:

thecardiologyadvisor.com/ah...

However, that risk factor is not included in the calculation of CHAD or CHAD2VAS2. That was exactly my point: the CHAD2VAS2 score is great, but it doesn't include every known risk factor - only the major ones.

It's a great tool, but even if your CHAD2VAS2 score is zero, there are other things we can do to keep our stroke risk down ... don't sit and watch television every day eating fries and getting drunk: exercise, eat well, keep your stress levels down etc

[seasider18 in reply to Thomps95]

Heck! I've had digestive problems since 1970 at least and have been taking PPI's since 2001. I had been taking other remedies in the four weeks when taking clopidogrel after having my Amplatzer Amulet fitted as they affect the absorption of it and am trying to continue without them. Previously after a few weeks I've had to go back to them.

[CDreamer]

Ooooh - can of worms - now open and wriggling..

[Thomps95 in reply to CDreamer]

Did you make popcorn?

[CDreamer in reply to Thomps95]

LOL

[Mazza23]

My EP told me I will take apixaban for the rest of my life in fact I am still on all meds

[Jumper]

Stroke risk increases with age increasingly so after 75.

I am 70 my CHADS2 score is 1. I do not take any anticoagulation therapy. My score is 1 because I have reached 70 with no other factors like Hypertension. My EP after discussion indicated he would review the need for anticoagulation when/if I reach 75 when my CHADS2 score will be 2 if I have no other factors.

As in Bob's earlier post ' has been suggested that it is not the AF which produces the risk but the company it keeps'. Hypertension is just such company and a particularly bad friend it is too contributing to at least 50% of strokes.

Hypertension is silent and one can remain ignorant of its consequences until its too late whereas AF is a constant troubling reminder that your heart isn't OK and in my case been so for some 17 years. I am now 8 years post ablation . Us AF sufferers tend to make life style changes because of the AF reminder. I would be much more concerned about stroke if I had hypertension on its own but would I know and would I change my life style if I did.

In answer to your question . My EP considers I have no need of anticoagulation even though my score is 1 and my last check up still indicated irregularities in my heart rhythm of less than 1% (ie ablation success). However it is not a permanent decision as my risk increases as I get older.

[rosyG in reply to Jumper]

I hope you keep well but just wanted to say that 6 minutes of AF can lead to stroke- so do think carefully about Acs. As we age our skin tissue gets rougher- as does the heart lining- so making it easier for clots to form when in AF

[seasider18 in reply to rosyG]

6 minutes is better than the 1 second that my cardiologist said was enough for a clot to form.

[Jumper in reply to rosyG]

In one of my earlier posts I referred to some info supplied by the Stroke Association. This indicated that some 8% of total strokes were attributable to AF alone whereas some 50% were attributable to Hypertension. With anti coagulation the incidence of strokes directly due to AF only reduces by around 3% of the total.

So anticoags aren't a full insurance against having a stroke with AF alone. ( Less than 40% effective for AF alone)

I have confidence in my EP's recommendation of me not having to take anticoags as , if you can believe the stats, if one has hypertension the risk of stroke is much greater than AF alone and anticoags are only partially effective in AF alone. Does everyone with hypertension take anticoags?

As I am a 'facts' man I have questioned my EP who I assume takes a holistic approach to my condition and makes a professional judgement based on me as an individual. A heart scan shows my heart to be normal. If it had shown some left atrial enlargement I would have been much more questioning about no anti coags, as left atrial enlargement is a major stroke risk for hypertensive individuals and, presumably, similarly if enlargement has been caused by AF.

Sorry to be a bore

[F-M-C-MM in reply to Jumper]

A bore you most certainly are not, positivity is good for the soul and the heart ! A holistic approach and a bit of common sense are needed. Flecainide was prescribed in my case and I was told I would be on it for life. It was a nightmare so I gave it up and am much better since.

[rosyG in reply to Jumper]

There are studies showing a much higher proportion than 8 per cent are due to AF It's your choice but the evidence is strong re AF and stroke

[Jumper in reply to rosyG]

Hi RosyG

You make an interesting point. Do you have the source of the info for me to read up on.

[rosyG in reply to Jumper]

Hi Jumper,

There are many studies on line- one shows AF is main factor in 22per cent of stroke- I have heard stroke consultants say a third is nearer the correct figure- I copy the statement below from stroke.org as this may be what you were quoting from?

• AF is a contributing factor to 20% of strokes in England, Wales and Northern Ireland.81

( source stroke.org)

[BobD Volunteer in reply to rosyG]

One must also remember that those 20% account for 80% of the most severe and least recoverable strokes.

[Jumper in reply to rosyG]

Thanks for that Rosyg.

The information that you referred to and what I referred to appear to hang on definitions/criteria.

ie AF a Contributing factor in 20% and attributable to AF in 8%.

I must admit it is confusing as both would appear to be correct.

I interpret this to mean a contributing factor includes other co morbidities whereas attributable means solely due to AF.

Thanks for your concern in this matter it's been stimulating!

[F-M-C-MM in reply to Jumper]

Thank you Jumper for a very sensible and balanced viewpoint, it just goes to show we are all different in our response to A Fib, and there are risks in every aspect of our lives. People with A F generally make significant life changes, and I would rate their chances as being quite good. It's encouraging to have a cardiologist like yours or an E P who trusts you enough to follow his advice, and who has the conviction that you don't need all the medication just yet. It makes sense to take Anticoagulation in one's 70's whether you still have A Fib or not!

[Hidden]

I am 62 post ablation Number 2 by 4 months with a score of 1 and have been taken off Apixaban in last 2/3 weeks. This was always the plan however like you because of the advise given here I was a little suprised because I'd had 2 episodes of AF since the operation. one was 2 weeks after one was at the stage about 6 weeks ago I stopped Flecanide. I did ask the consultant and his response was that the risk factor was 1/100 of a stroke and 1/100 of a bleed from taking it. I would say that since stopping Apixaban I do feel a bit more grounded and the thick heads have improved. I have kicks and flicks every day and my overall health and strength is poor but I seem to be settling a tiny bit at the moment so I hope the small improvement continues. I certainly feel that the AF could return but I also live in hope it won't.

[Mike11]

I would take issue with " if the ablation is deemed to be a success and all arrhythmia have stopped". My ablation was a success but a virus suddenly caused my heart to expand and put me back in AF until my body had fought off the infection after a whole month of AF. If I hadn't have been on anticoagulants for life might the sudden onset of AF have triggered a stroke ?

[BobD Volunteer in reply to Mike11]

Mike my point was if you had a CHADSVASC of zero you wouldn't be on anticoagulation other than for the purpose of the ablation so it seems common sense that you do not need it afterwards. Personally I feel that even with a CHADSVASC of 1 and successful ablation it is worth continuing anticoags for the very reason you put. It is always a balance of risk/benefit .

[Mike11 in reply to BobD]

I think this is where CHADSVASC falls down. If you've had an ablation then AF WILL return ... you just don't know when and for how long. Provided the anticoagulation doesn't have any side effects on you, then being protected seems a good idea to me.

[F-M-C-MM in reply to Mike11]

Hi Mike11, Are you speaking from personal experience when you say after ablation AF WILL return or are your views based on some study or findings on the effectiveness or otherwise of the procedure?

[Mike11 in reply to F-M-C-MM]

It's an effective procedure but no EP will tell you it's guaranteed for life. My first one worked well and so far it's all I've needed, but others here are on their third/fourth/....

[BobD Volunteer in reply to Mike11]

Not sure what the current statistics are F-M-C.MM but five or so years ago it was 50% return within five years. I'm 9 years AF free but lots of other arrhythmias and have no intention of stopping anticoagulation. Why when it's affect on my life is pretty minimal? A few brittle nails and the odd bleed for a few minutes if I stab myself are a small price to pay for peace of mind. OK I am careful with my chainsaw and power tools but I don't live wrapped in cotton wool as most know.

[Chaben]

My electrophysiologist told me it (stopping the blood thinner) would be determined by results. I also believe is determined by other underlying issues.

[tony85]

I think will be very dangerous to go off anticoagulants. After taking them for a few months you need to have your INR checked monthly. Most people have no side effects from wafaran , the drugs are very cheap so why not go on taking them

[Phylis2005]

I have been on Xarelto before and after ablation which I had 8 weeks ago. My main complaint is the fatigue at the end of the work day. I am 75 and I work 3 to 4 days a week. Every now and then I experience some flutters but I am glad that I am on an anticoagulant (my own security blanket). Just wonder if the fatigue will ever go away. Phylis2005