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AF Association
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New to the site and would like experiences of anticoagulants

I am a 56 year old male and have had AF for about 8 years. Until recently I only had a few attacks per year lasting anything up to about 8-10 hours. I was on twice daily flecainide which seemed to be quite effective but recently the attacks have been coming much more frequently and for longer. I am a diet controlled diabetic as well. I have recently been told I need to go onto anticoagulants and have some information. My previous working background involved treating people on anticoagulants. but now I need them myself, other people's experience would be very helpful. The advantage of the newer NOAC's seem to be less monitoring, but the disadvantage seems to be that there is no antagonist in case of any severe bleed. Warfarrin needs more monitoring but there is an antagonist in case of a bleed. Other side effects may also be available in all cases. I was hoping that an ablation may be the definitive answer, but it would appear that this is not the panacea I was looking for. On talking to people and researching there appear to wildly differing treatment regimes depending on where you live and who you see. Any thoughts greatly appreciated

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Hi birdman and welcome

Most of us would be on an anti-coagulant, and I suspect if you took a straw poll the majority now would be on a NOAC.

I would correct one point Dabigitran does have an antagonist licensed now, and there is one on the way for the other 3.

However if I were you before you look at the potential of a bad bleed decide which drug suits you best, for some people it is still warfarin, and then once you choose the one that suits you, then take a look at any paper on "dealing with a serious bleed in trauma and anti-coagulants" What I think you'll find is that whilst yes of course they use the antagonists, they are not generally used except as an adjunct for the serious trauma type bleeds which I suppose we all fear, you will find that the process for those is the same if you are on warfarin or a NOAC.

Personally, that's the decision path I went down when I switched from warfarin to Rivaroxaban, and not had any problems since

Be well

Ian

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Morning all, I am not professing to be an expert but I can only relay my own experience.

I started with treatment for my PAF when I was in my early 50s after being hospitalised for a severe attack. I sailed in Caribbean on my (now) husband's sailboat for a few years with no serious incidents and the drugs seemed to control it, but there was always the fear!

The Cardiologist decided the best course was an ablation and advised I should be started on Warfarin under GP care. Before the treatment began, we went to the Canaries.(we flew). the day after we returned I had a massive stroke and I have been left 8 years later with limited mobility on my left side.

Had I delayed my holiday and started on Warfarin I believe I would not have had the stroke or maybe the effects would not have been so debilitating?

I personally have had no adverse reaction to Warfarin and I prefer that my INR is checked regularly. It is merely inconvenient when the INR varies because I have been taking antibiotics. As for 'bleeds' I have no problems with cuts and grazes.

But I emphasise this is only my personal experience. I would say "Warfarin? go for it-keep those blasted strokes away"

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I have been on Warfarin for 30 years without much difficulty. Now that I can self-test I only go to the anticoagulation clinic twice a year to ensure my testing machine is properly calibrated. This has given me enormous freedom. My INR has to be a target of 3.5 and at the moment there don't appear to be any NOACS to cover the higher INR range requirements so the first thing to learn is what your target INR is. If you are suitable to take the NOACS or Warfarin then you do have an added choice. Anne

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Hi Birdman, first I would say is to stabilise your AF, maybe increase your Flecainide if you are just on 50mgs x2 daily with medic approval of course.

Second at 56 yo male even with the diabetic co-morbidity (if its the only one) I suspect taking anti-coagulants is borderline. As well as major bleeds, I have read as you would expect that some believe there are other downsides to your health with anti-coags. Personally, I avoid any pills until the medics say 'you have to take them or else....' but I do use the real stroke risk, however big or small it is in my case, to remove complacency and push me into a much healthier lifestyle all-round. Good luck.

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Welcome!

Since my last serious attack my local hospital transported me to Buffalo General . They are well know heart center. Anyways the specialist tried several medications and finally settled on Cardizem And Digitek plus warafin and magnesium. Few weeks later both him and my regular heart Doctor decided that on a risk level I only had one factor being a female, so they took me off warafin and put me on low dose aspirn. I rarely feel any fibulations and my blood pressure is perfect. It's been 8 months now. What a difference not to think about and be aware of my heart 24/7

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Hi I thought that aspirin wasn't recommended for AF, I don't have much knowledge on this subject though, just a Query.

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It isn't Stivvy. It can cause harm (GI bleeds) for little benefit , It still has uses . just not for stroke prevention in AF but not everybody gets that yet. Here in UK it isn't recommended .

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Hi . How much magnesium did the hospital recommend and what type

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It's all about weighing up the risks. If you have PAF then you are at a higher risk of a serious stroke. A bleed due to trauma, although serious, would probably however be much less likely.

I went through this thought process before I started on Dabigitran. In my personal view I considered my risk of a stroke to be higher than my risk of a major bleed.

There's some useful information on the AFA website: healthunlocked.com/afassoci...

If you're in the UK then you might also consider coming along to the AFA Patients Day in October: healthunlocked.com/afassoci...

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Have been on Rivaroxaban for 3 years and apart from early bleeding gums occasionally I am very assured knowing it is protecting me.

Good luck with your treatment

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Drowding. Why do you say PAF has a bigger stroke risk. I have PAF and my EP told me that my stroke risk was 2% .

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Thank you very much for everyone's input. My GP told me there was no antagonist to NOAC yet, but there may be soon. I think the case for the anticoagulants is fairly borderline, but my diabetes has been a bit less well controlled. The recent frequent attacks (daily up to 18 hours at a time) and appeared to coincide with starting metformin and starting a lower carbohydrate diet. I am not sure if this was a coincidence But I did read somewhere reputable that metformin could cause problems, which was pooh-poohed by my cardiologist. I have stopped the metformin but continued the lower carbs, which been very beneficial in losing weight. The fibrillations lessened until about a week ago, when they started up again daily, although not as long as last time. I'm not desperately happy about starting on anticoagulants as I do tend to get side effects with a lot of medications, but I really don't fancy risking a stroke, so I suspect I will go on one. Someone mentioned home monitoring of warfarin. Is this with a coaguchek and is this in the UK? I used to use one of these at work from time to time for my patients before taking teeth out, so am very used to it, although I treated it with some caution. I know some cardiologists felt they weren't especially reliable, so it's interesting to to see that some are offering calibration, assuming this is available in the UK. Were the devices given to you or did you buy them yourselves? Comments about aspirin also interesting as I have been on a low dose since this all started.

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Take a look at this site on Medscape. You may need to log in. This site will not send you email except on the subject you request.

medscape.org/viewarticle/89...

Since so many on this site wonder about NOAC's, I posted the first page of the study released on Feb 12, 2018. There is more on the link. My concerns would be: 1. Does the hospital have the antidote? 2. The corrective process is quite involved so how many doctors know it, have access to it, or remember it if they only encounter this situation on an infrequent basis? But this likely applies to many things they do.

The first page:

One of the most feared complications of treatment with oral anticoagulants (OACs) is major bleeding. The current guidelines from the American College of Cardiology (ACC) define major bleeding as a bleed in a critical site that compromises the function of an organ, bleeding accompanied by hemodynamic instability, or bleeding that results in a reduction in hemoglobin levels of 2 g/dL or higher or requires administration of at least 2 units of packed red blood cells (PRBCs).

The authors of the current guidelines describe the general best practice for patients with major bleeding, regardless of the use of OACs. They advocate for aggressive fluid resuscitation with crystalloid solutions. Hypothermia and acidosis can worsen coagulopathy and require correction.

A more restrictive transfusion policy for PRBCs is associated with improved survival and a lower risk of rebleeding in cases of severe acute upper gastrointestinal tract bleeding. These patients may undergo transfusion to achieve a target hemoglobin level of 7 g/dL or higher. However, a more liberal transfusion strategy, with a target hemoglobin level of 8 g/dL or higher, is appropriate for patients with a history of coronary artery disease.

Clinicians should also be aware of organ dysfunction, which might promote coagulopathy. All direct OACs (DOACs) depend on renal clearance, so patients with renal dysfunction treated with DOACs are at a higher risk of severe bleeding. Among patients with liver disease, plasma given at large volumes may increase portal pressure and increase the risk of further gastrointestinal tract bleeding.

The current guidelines from the ACC focus on the best response to bleeding associated with OACs.

Synopsis and Perspective

The ACC has issued an expert consensus document, with "decision pathways" to guide clinicians in the management of major or minor bleeding in patients receiving OACs.[1]

The document, published in the December 19, 2017, issue of the Journal of the American College of Cardiology, complements the 2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation.[2]

"The primary objective of this decision pathway is to provide a clinically applicable, easily referenced conceptual framework to support clinician decision making while caring for patients with bleeding complications during [oral anticoagulant] therapy," writing committee chair Gordon F. Tomaselli, MD (Johns Hopkins School of Medicine, Baltimore, Maryland) states.

"The manuscript really helps to come up with decision pathways in first assessing the level of severity of the bleed, understanding how to use reversal agents, when to restart your anticoagulation, and how to do that," writing committee member Roxana Mehran, MD (Icahn School of Medicine at Mount Sinai, New York, New York) told theheart.org | Medscape Cardiology.

"We did talk a lot about the DOACs -- when the special assays are available and when they're not and what to do as far as lab measurements," she added, and the document also has an "important section on clinician-patient discussion."

Six easy-to-follow sequential treatment algorithms and 7 comprehensive tables accompany the text.

"One of the nice things about [this guidance] is that it really does give you great graphics of how to go from one step to the next, by answering questions 'yes' or 'no', and moving into the different algorithm," Dr Mehran said. "That's the most unique portion of this important document."

The document addresses bleeding that arises from treatment with a DOAC -- dabigatran, rivaroxaban, apixaban, or edoxaban -- or a vitamin K antagonist (warfarin), for any indication, including atrial fibrillation in the absence of a prosthetic valve or venous thromboembolism.

Major bleeding is defined as "bleeding that is associated with hemodynamic compromise, occurs in an anatomically critical site, requires transfusion (≥2 U of packed red blood cells), or results in a hemoglobin drop ≥2 g/dL."

All other bleeding is defined as nonmajor bleeding.

"The assessment of bleed severity in patients treated with OACs and/or antiplatelet therapy is crucial for treatment decisions to achieve hemostasis and preserve organ function," the document stresses.

"Measurement of anticoagulant activity is a key step in the evaluation of an anticoagulated patient who presents with clinically relevant bleeding," they add, going on to describe how to do this.

Patients taking a vitamin K antagonist may be evaluated with the prothrombin time/international normalized ratio (INR). The best tests for assessing the anticoagulant activity of dabigatran include the dilute thrombin time, ecarin clotting time, and ecarin chromogenic assay; and the preferred test for assessing apixaban, edoxaban, and rivaroxaban is a chromogenic anti-Xa assay, but these tests are not widely available.

The authors provide 2 tables with suggestions for laboratory measurement of DOACs, when specialized assays are available and when they are not.

They go on to provide a detailed explanation of how to manage major and minor bleeds and then discuss OAC reversal strategies.

"In a life-threatening or critical site bleed or in situations in which bleeding cannot be controlled, reversal of OACs is required," they write. Reversal agents include repletion strategies such as a prothrombin complex concentrate, plasma, vitamin K, and idarucizumab for dabigatran.[3]

The document describes considerations for restarting and for delaying anticoagulation.

"Optimal patient engagement in the decision to restart anticoagulation involves shared decision-making with patients and care providers," they stress. In a table, they summarize what to discuss.

The expert consensus also covers medications that increase the risk for a bleeding event, gastrointestinal tract bleeding, intracranial hemorrhage (the most feared complication of anticoagulation therapy), and restarting anticoagulation after a surgery or procedure.

The ACC has 2 related free apps for clinicians, Dr Mehran points out.

The updated AnticoagEvaluator app[4] is designed to help clinicians make informed decisions about antithrombotic therapy for patients with nonvalvular atrial fibrillation, and the BridgeAnticoag app[5] is designed to manage anticoagulation around an invasive procedure for a patient with nonvalvular atrial fibrillation.

"Patients who require anticoagulation are an at-risk patient population," she said, "and I think improving the quality of their health outcomes . . . is crucially important, so this expert document in the important decision pathways will hopefully help develop that."

Dr Tomaselli has disclosed no relevant financial relationships. Dr Mehran is a consultant for Janssen Pharmaceuticals and has received research funding from AstraZeneca, Bristol-Myers Squibb, and CSL Behring. Disclosures for the coauthors are listed in the original study.

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My sister has done a lot of research on diabetes and a chiropractor in Tampa Florida has helped her husband, through diet and chiropractic adjustments, get off Metforman and significantly reduce the amount of insulin he uses. I sent her some YouTube videos on diabetes by Dr. John Bergman. She says some of his ideas have merit. You may wish to take a look at these videos.

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In the last week or so, I posted Heart Arrhythmias - the Missing Cause. This is a YouTube video by Dr. Bergman. From my experience, his conclusions about parasympathetic and sympathetic nerves have merit.

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