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AF Association
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Anticoagulation

I am just asking this out of interest. When I was diagnosed with AF I was informed that the danger of AF is that a clot may form in the left atrium . This is caused by the irregular heartbeat/very fast heartbeat as the blood pools in the atrium and may clot. Now I read on this website often that people have had an ablation and/or been successfully treated with medications and have not had an attack for several years and so the only medication they take is an anticoagulant. Surely it must follow that if there are no AF attacks then there is no danger of the blood pooling why take an anticoagulant? I am aware that there may have been some damage to the structure of the heart but if this is not the case and there are no attacks why anticoagulation?

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There is little evidence to suggest that successful ablation removes stroke risk hence so many of us prefer to remain on anticoagulation. The idea that success means stopping is a common erroneous one. To further expand one must say that this does depend on what your risks were prior to getting AF. So for example if your CHAD2VASC2 score was zero and you only went on anticoagulation for the purpose of having the ablation then continuing may be optional but if your risk was high anyway (2+) then I for one would not dare to stop. (My score now is 2 - age and high BP- but was only 1 post ablation and my EP said I could stop. I didn't!)

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Thanks for that but it doesn't really answer the question which is ...... how is there a risk of having a stroke if there is no longer a likelihood of a clot forming?

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Maybe because it's there as a precautions incase the procedure doesn't work or stops working I have no insight to all this as have only been diagnosed 3 weeks ago but I think I would rather have a safety net in apixaban than a clot in my heart I maybe be wrong but I'm willing to learn

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But there is. The whole correlation between AF and stroke is complex . Ablation can create changes to the surface of the atrium which makes pooling likely. Also as Dr Sanjay Gupta commented in one of his many videos it is not necessarily the AF which causes the stroke but the company it keeps. This is why I stated that it depends on your CHADS2Vasc2 score . If you had zero risk other than merely the AF then that doesn't change. You would have been put on anticoagulation to prevent clots forming during ablation and recovery. IF on the other hand your score was 2 or over then your risk is likely to be independent of whether on not you still have AF.

Of course nobody can force you to continue to take anything and it is about risk management . I freely admit that I was very keen on stopping and could not understand why I shouldn't but having listened to people I trusted that view changed. My warfarin intake these last fifteen years has had zero effect on my life but a stroke would.

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Ok thanks Bob. I guess it is a question of choice...my score is 2 because I am over 65 and female but I have no other comorbidities I.e. diabetes, high blood pressure etc. Therefore I did think that maybe if no attacks then why anticoagulation just because I'm female (sexist ha ha!) And over 65. However I do accept your point about the surface of the atrium so thanks very much for that.

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If you read through my old posts you will see I was asking same questions a few years ago - I came off AntiCoagulants after successful ablation (2nd) but told as soon as I was 65 I had to go back on them, didn’t want to so resisted. I went back on them when AF episodes came back, I couldn’t wait to get back on them. Despite that I had a TIA last October, which thankfully recovered quite quickly from.

I learned it is the one thing you DO NOT mess about with if you have a CHADS of 1+!

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What is your take on why A-Fib came to you? Mine was triggered by allergy -asthma medication although I feel I did have it in a milder form earlier.

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No idea - I was very fit & healthy and came out of nowhere. 2nd episode was whilst I was sailing on a small yacht - mid Atlantic so nothing much I could do so just sat it out.

We found out my father had AF for the last 20 years of his life and many report that it runs in families. In my fathers’ generation it wasn’t talked about & we didn’t know until we saw it as one of the conditions in his medical file.

No-one knows what cause AF but there are some underlying conditions closely linked to it - thyroid disease, sleep apnea, other cardiac structural consditions.

It’s not something I worry about any longer.

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with A/F there is always a risk of clotting because the heart can be erratic in those who are susceptible/prone to it even post ablations, which don't always work 100% anyway in eradicating A/F.

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Possibly because the af could return at anytime. It sometimes comes back after ablation.

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Obviously I too would rather have a safety net in apixaban than a clot in my heart but it still doesn't answer the question.

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I don’t thing there is a cause and affect answer but all the studies do show this correlation.

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Well hopefully Bob has now lol He is pretty well up to date with his information .I have found out since I joined

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There is also the possibility of Atrial Flutter starting even after successful ablation for AF. AFlutter carries the same risk of stroke as AF.

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Wow! I did not know that!! Thanks .

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Hi Rothwell :-) you say...

''Surely it must follow that if there are no AF attacks then there is no danger of the blood pooling why take an anticoagulant? ''

How do you know there are no attacks that is the thing. Medication and ablation treat the symptoms of AF in order to give a better quality of life and the symptoms may disappear but the AF can remain as a 'silent' condition or return at some time.

I thought a lot of my episodes of AF had disappeared because now I am on medication I get fewer bad episodes and was shocked when routinely checking my BP to find I was in AF without my knowing.

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Does a normal BP machine let you know when your in af

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Hi Vonnie :-) many BP machines only register BP, mine has a symbol that shows an 'irregular heartbeat' (but not specifically AF) and if it does a quick check of the pulse can confirm if it is AF.

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Mine shows my pulse and BP is that any good

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Unless it is specifically a monitor which states it will cope with arrythmias - no, it’s no good as you will get erroneous BP readings as well as HR readings.

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Doodle what make is that

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Hi Vonnie :-) I have one of these it is similar to the one my GP uses...

amazon.co.uk/dp/B00IIOI9FS

It has an 'irregular heart beat' icon. It also saves 60 BP recordings. I have high BP so it is useful for me to record my BP as instructed by my doctor .

I would not rely on the BP monitor to always detect an irregularity, that is not its main purpose...

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Just had a look doodle Still a bit dear as I'm only on £82 per week ssp

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Omron makes a good home monitor. When I was in active A-Fib the heart beat symbol was all over the place and the monitor would not register my blood pressure as the A-Fib beats were like flapping fish.

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See I don't even know what AF I have

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Yes i have one from Boots that indicates BP,pulse rate and Irregular beat

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Was it dear and can you give me model pkease

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It is my understanding that over time, AF can change the structure or texture of the heart which could possibly cause clots to occur which an ablation would not improve, on the contrary, as an ablation can also change the surfaces of the heart. Also, bear in mind AF can return at anytime, often when asleep and many people are unaware if this happens. Personal choice of course, but not a risk I am prepared to take and I only score 1 on the Richter scale!

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We..ah..that’s scary.

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Sorry, didn't want to be scary!! As I said, it's my understanding, but happy to hear from anyone who disagrees......always better to be aware of these things than not.......

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Ok ....convinced. Thanks everyone.

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The other train of thought might be; The general consensus seems to be; Afib is not as such....curable, (although some may argue differently), you could say the jury is out on that one!

Therefore, leaning on the side of caution, would it not be better to keep on taking an anticoagulation, as you only need to have that one Afib session out of the blue - to have a stroke?

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Let's be quite clear - there is a possibility of a clot forming leading to a heart attack or stroke in most of the population whether you have AF or not. Whilst there are people where anticoagulation is contra-indicated, I personally believe that we would possibly reduce the number of deaths from these 2 out of the 3 biggest killers by being a little more liberal with the anti-coagulants just as we are with statins. Whilst the statins did delay my heart attack by about a decade, I am convinced I could have delayed it further had I been on anti-coagulation as well. This required me to have a heart bypass and the stress of this led to my AF which needed an ablation to fix. So two £25k operations and about a year seriously reduced income could possibly have been avoided with some cheap warfarin tablets.

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Quote Mike....

''Whilst there are people where anticoagulation is contra-indicated, I personally believe that we would possibly reduce the number of deaths from these 2 out of the 3 biggest killers by being a little more liberal with the anti-coagulants''

.....Hi Mike :-) Dr Gupta in one of the videos I watched yesterday said he believed people with AF and a CHADS score of 0 should be anticoagulated and as someone who had a score of 3 and was still reluctant to take ACs ,after reading much on the subject I am inclined to agree with youself and he....

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Hi there.

Have you had an ablation ? Or are you AF episodes infrequent ?

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Does watchman or lariat procedure arguably reduce need for anticoagulants?

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I had my atrial appendage closed off by something that looks suspiciously like a clothes peg, during a heart valve repair operation. The thinking at that time was that the heart would allow the blood to pool in the appendage and possibly cause strokes.

I recently read that this thinking has recently changed and the appendage may have a role in controlling blood pressure. Unfortunately I didn't keep a record of this report. Such is life.

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Go to Dr. John Mandrola's website or twitter feed for his analysis of Watchman which is not favorable. A recent report I believe shows that some clots can be formed by the procedure itself which seems troubling.

Jim

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After my ablation 4 years ago, the doc told me to continue on 2.5 mg Warfarin and Diltiazem for three months, have a check, then stop. I did that and haven't taken anything since. No mishaps. INR is 1, waking pulse 65. My basic m.o. is to resist many doctors' reflex to prescribe until I'm given some proper explanation/data to refer to. In my case Rothwell, and luckily, my doc was a conservative prescriber. Suggest politely interrogate your doctor and request a med-free pathway/objective.

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If you have a CHADS score of 0, what about simply taking tumeric or baby aspirin, giving some anticoagulation without necessarily the high bleeding risk of Warfarin, Rivobraxan etc.?

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In the US, you would not be given anticoagulants with a Chad score of 0. Anticoagulants is a strong drug witch can have bad side effect with micro bleeds. I know to say this is not well accepted on this web site.

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Oh and by the way, a better route to an anticoagulant-free regime is to regularly include some or all of the dozen (or so) blood thinning foods. Then your quest for an answer will be over 😉

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A recent study suggests that selective populations may safely stop thinners after a successful ablation.

news.heart.org/study-afib-p...

It's often a shared risk management decision with no right answer. I haven't had an ablation but have a history of paroxysmal with episodes either years apart or of very short durations. One EP said I should be on thinners, another said it was reasonable not to take them for now.

Jim

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A more recent news article 14 May 2018 ..

''Nearly 150,000 patients who have had their AF resolved remain at a high risk of stroke and should still be treated with anticoagulants, researchers have said.

A study in the BMJ has found that patients with AF marked as ‘resolved’ had a 45% increased risk of suffering a stroke when compared with patients without any history of AF.''

pulsetoday.co.uk/clinical/c...

There are so many studies you can take your pick ..

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Doodles, As is often the case the difference is in the details. The study you cite is for "resolved afib" Resolved afib is defined by the sudy authors as "...AF resolved’ means that patients are no longer followed up and within three months 90% have stopped treatment.

So this study is for patients who are no longer being followed. For all we know, a percent of them may be in permanent afib. The study I cited stated that thinners may not be necessary in "selected populations" which were defined as patients with successful ablations who WERE being monitored and showed no new events.

I'm not saying that differences of opinion on this don't exist within the medical community, or that reasonable people could decide either way, but again your study only pertains to unmonitored patients so I am not surprised.

Jim

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Great question. 85% of stroke victims do NOT have Afib. Eliquis has almost crippled me from with joint and muscle pain. I have now cut them in half. It has helped a little bit I need to get off them all together. Also they are changing the CHADS score in some countries to 3 for women and 2 for men. Because I have no other conditions except age and female my EP said I will probably not need thinners after my ablation :)

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Do you know which countries are changing the CHADS score guidelines?

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This has been posted previously - it is the NICE decision tool information on anti coagulation

nice.org.uk/guidance/cg180/...

It compares Cha2ds2vasc risk of strokes against HAS-BLED score - risk of bleeding on anticoagulants

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I am perplexed and thinking of cutting my eliquis dose in half because someone posted this elsewhere and its disturbing "Eliquis may help prevent an ischaemic stroke from afib but can cause me to have a hemorrhagic stroke according to Dr. M. Edip Gurol’s comments published in the March 18, 2018 issue Cardiac Rhythm News. A stroke neurologist specialist at Mass. General Hospital, he has a particular expertise in the care of patients at high risk for ischaemic (blockage type) strokes and haemorrhages"

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Does elquis work like that? Can you take a smaller dose? I ask as although I know nothing of Elquis, I was on Pradaxa (dabagitran).

The ADULT dose for Pradaxa is 150mg twice a day whatever size you are except if you are also on other anti coagulants or you are over 80 years old in which case there is a special 110Mg tablet. (children are not allowed Pradaxa).

I am also perplexed at the (apparently) contradictory statements. I only went on Pradaxa as I was having an ablation.

3 months after the ablation I am off it as my Cha2ds2vasc is zero and I do not seem to have AF anymore.

My EPs believe the risk of bleeding is greater than the risk of stroke for me (I am almost 58).

I never wanted to be on A/Cs - they scare me as I am quite active (or was pre-af ) so the risk of a bike crash, bang on a mouintain climb/scramble or even owing to a slip on a run cross country is possible.

Having said that I had no issues at all with my 4 months on Pradaxa, I never saw any extra bruising and the increased bleeding for cuts, gums I had was not major so if I ever get a higher chads score I will consider it.

However 4 months on the drug is probably a lot different to 20 years on it!

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