AF Association
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How would you feel if your doctor told you to stop taking your anticoagulant, or any other, permanently ?

I'm nearly 70, I've had one ablation for paroxysmal atrial fibrillation, and I've taken Warfarin for ten years with good INR control and no problems from the Warfarin as far as I know. If I was told to stop taking it, I would be anxious about the lack of protection against stroke.

But I am starting to get unsteady which has been diagnosed as due to a damaged vestibular nerve. I have not had any significant falls, but I have to be careful. I suspect I will have a bad fall one day, it might not be until I am 80, but if I am still on Warfarin at the time, a head injury would likely have worse consequences.

I accept that we should take an anticoagulant if we have AF but I don't fully understand the benefit and risk of doing so as we move in to old age. I don't know how strong the evidence is.

I think the only doctors able to give good advice on this are geriatricians. Most hospital consultants know little of medicine beyond their own specialty leaving GPs as the only generalists. And they can't be expected to make complex decisions in the little time available if they don't know the patient well.

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Difficult question and one we really can't advise on. You are still young at present and a lot can happen in the next ten years so I would not be too keen to start worrying about that right now. My only thought is that a change from Warfarin to a DOAC may be beneficial as there is some evidence that cranial bleeds may be less common on those, not that they are actually common.

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Thanks Bob. I would say that cranial haemorrhage is not uncommon following head injury in elderly people taking anticoagulants.

If I start falling more regularly, I will find an experienced geriatrician to help me decide whether to continue with warfarin.

Having experienced a fair amount of indifferent medical care down the years, I tend not to be a passive recipient of medical advice.

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Good for you.

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Warfarin or Abixaban? As Badger says- with often indifference medical care hard to level -up pros and cons.

Abixaban seems more aggressive and relatively new compare to Warfarin.I am very reluctant to take any, but with PAF cardio.dr. Insist on Abixaban with no answer for how long.

Now, When I wanted to do colonoscopy, it was refused due to Abixaban taken. To stop it - might create clots also, as med. notation explained . Catch 222.

Also, perhaps ,i would required gallstone removal. Stopping anticoagulant would be required, I assumed.Any thoughts?

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My dad was on warfarin for many years,and had 2 ops for bowel cancer and one for broken hip.They deal with it by using Cloperil...think that's the drug...in a planned run up to your operation,all done very well.

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Thank you Wilsond for reply.

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Hi Alemo. Permanent anticoagulation is usually advised and is pretty safe generally. Yes oral anticoagulants are stopped for most procedures but given by injection as necessary. All pretty routine nowadays.

Are you going to have an ablation?

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I am on Abixaban due to occasional rhythm skipping, I do not let it bother me for hours., and taking Bisoprolol ,as a PRN, usually stops skipping . But cardiologist said, that these occasional ( a couple times per week) palpitations plus the age factors can produce blood clot , and is required the anticoagulant. I do not going for any ablation.

So far, I cope with what I have.

I want to go for colonoscopy and possible gallstone operation. And this is rose my question about anticoagulant.

Dr.Sanjay Gupta is UK Cardiologist. His web site: www.yorkcardioiology .co.uk. He keeps updating his video/lectures about PAF,PVS Tia , etc.

Very informative !!

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I take Apixiban and have had colonoscopy,TOE,endoscopy and presently awaiting a angiogram all without having to stop my anticogulant. I did query it but was told it was more to do with if you took warfarin and that it wasn't so precise with Apixiban which has a half life of 12hrs. Hope this helps.

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Thanks Cali, I had not realised that. A big advantage of the NOACs in that situation then.

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well neither had I but as I researched on line I came across it. it was not mentioned until the angiogram appointment was sent to me and the cardiologist said it would not be stopped as I had a residual clot in my heart I am waiting for an operation to remove this and a surgical ablation at the same time. I forgot to mention that I had a tooth extracted last year and again was advised that I did not need worry on the Apixiban. I was advised that although it would take longer for the bleeding to stop it was nothing to worry about. I was on warfarin but I requested a change when the research through up the fact that Apixiban was more effective for preventing strokes and clots. I am now 73yrs old.

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I think if you get to a point of 'falling regularly' then you need to be considering protective clothing. Women with osteoporosis are strongly advised to wear hip protectors and if you're worried about your head then perhaps a head protector is a good idea.

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My Mom took Coumadin for years for A-fib. In her last years she fell a lot so her doctor put her on 2 baby aspirin and she did fine.

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Thanks G. That does sound sensible in that situation

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My EP put me on Apixaban specifically because I told him my main concern being anticoagulated was a cranial bleed. He said Apixaban has a reduced risk of a brain bleed. But would it make any difference with a knock on the head...pass!

My 93 year old father-in-law is on Apixaban (low dose) and he's at high risk of a fall, and he's had quite a few, but not knocked his head yet fortunately. He was put on it due to him having a stroke last year.

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Thanks Koll

Well I'm surprised. If your father in law becomes confused, he might need a CT brain scan. A subdural haematoma can easily be missed in exactly his situation if he gets even a minor bang on the head. If it is spotted early on the outlook is often good if it can be drained. Obviously if it isn't suspected and anticoagulants are continued, it will likely get bigger.

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My father was put on warafin about 10 years ago after a couple of TIA's, he died last year aged 94. In the last two years of his life, espcially the last 18 months he had number of falls, mainly causing gashes or severe cuts all of which needed medical attention a couple of them via A & E. He did bump his head once that we know of.

It was never suggested by his GP or the Hospital that he come off Warafin because of his falls but he did say himself that he would take his chances, he did not want to have a stroke and all that could come with that.

I am 70 have AF and am on a NOAC Rivaroxaban and I feel the same as he did, not that I fall about at the moment lol

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Thanks Cassie. Was the matter of stopping Warfarin raised by his doctors? I hope so because that was arguably quite a risky strategy in his situation.

My argument really is that the balance between risk and benefit of anticoagulation is generally towards greater risk at such an advanced age.

Apparent dementia, confusion and falls can all be associated with intracranial haemorrhage, without any evidence of stroke.

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Hi Badger

It may well have been discussed with him but he did not tell us - that would be typical of him - would not want to worry us. As I have said a stroke was his worse fear so his choice was to carry on taking warafin. He had no dementia or confusion in his final years so his falls did not effect him in that way. Like many things that have a risk factor after gathering all the info for and against it is upto the individual in the end.

Cassie

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Interesting this because I have recently been taken off all anti coagulants because it is suspected that they have been causing some internal bleeding leading to severe anemia.I was told that in my 70s a bleed is as likely as a stroke so we will see.

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Hi Parkey

My father had this in his last 5 years. He sufferred from anemia and was given medication for it he also had a few blood transfusions when really bad. He had lots of tests and investagations to find a bleed but they never found anything. I do not know if it was discussed with him about coming off warafin but he never said anything to us and his GP and the Hospital never said anything.

If it was discussed he would have asked to stay on warafin as I said he was more concerned about having a stroke than a bleed. We did about 3 years ago ask if he coud go on a NOAC but GP said no - never really got exactly why - GP was not much of a NOAC fan at the time I think.

Cassie

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The apparent lower risk of cranial haemorrhage with warfarin compared with the NOACs is only down to poor INR control in the trials. If you get OK control (>70%) then results are similar, get good control >80% and warfarin is actually superior. So I would suggest to Badger75, that as long as his control is good, he's better sticking with warfarin.

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Thanks Mark. Reassuring.

I'm guessing you meant higher in line one of your post.

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Yes indeed I did!

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I think doctors, regardless of their area of knowledge or specialization, may not be clever when it comes to comparative risk analysis. You see some people post ablation (like me) taking no anticoagulants and others who do. It's like a 36 year old woman who wants an amniocentesis test to check her unborn child for Downs syndrome. She does this because she wants the option of abortion. The likelihood of the procedure leading to miscarriage is quoted and scare the woman. But the odds of having a Downs syndrome child might be quite high. But the odds can't simply be compared. The consequences also have to be compared to assess the risk. The consequence of losing a healthy child versus a lifetime of caring for a Downs child also have to be considered.

The same issue of Risk = likelihood x consequence exists for anticoagulants. They increase the risk of cerebral haemorrhage compared to not using them.

I think if you are uncertain you should consult several physicians until you feel comfortable with information you are receiving as a basis for making your own choice.

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Well that is very interesting. Thank you.

I remember George Alberti telling me that 95% of published research in clinical medicine can be disregarded because of poor methodology or the application of inappropriate statistics.

Separately, the risk of an adverse event may be miminal, but the consequence devastating. Or vice versa.

Bizarre as it may sound, when I am 93 and falling all over the place, I will probably choose to continue taking Warfarin, mitigating all the usual risks, but also putting on my crash helmet first thing in the morning.

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Badger, thank you for your post.It is food for thoughts. I am close to 80 ,and did not have accidents of falling so far,thanks god, I am very concerned about anticougalant that my Cardio dr. Insist on taking .

Not to be a passive recipient, as you said, I am taking Abixaban once a day, after slightly hit my leg once and having a big hemorrhage.It took an over month to dissolve.

It is interesting to know the opinion of cardio dr. ,having PAF themselves, and being in this post.

Is Dr. Gupta have any topic for PAF patient receiving the anticoagulants med.

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What particular worries do you have about the Apixaban? Unless there is a good reason not to, there is a clear benefit in taking it once your Cardiologist has recommended it.

Who is Dr Gupta?

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Dr Sanjay Gupta is a cardiologist at York hospital - he has done a lot of videos on youtube about AF, each video is about different aspects of AF from ablations to ectopics to side effects, covers nearly everthing really.

If you google sanjay gupta you will find them.

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Thanks Cassie

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