Anticoagulation again or not?

[lizzily]

Our new GP wants to restart my husband (age almost 76) on anticoagulants. He had a successful ablation 18 years ago for atrial flutter and apart from a few very infrequent ectopics has had no recurrence. All meds we’re stopped post op but 5 mgs of Bisopralol was prescribed 3 or 4 years ago when the ectopics were a nuisance. I remember reading that even with a successful ablation the stroke risk remains and he scores 2 on the CHA2DS-VASc for age with no other risk factors. HAS-BLED score with age and a glass of wine a night puts him at moderate risk of a bleed!! ......so would starting again be a wise move........?

[Aprilbday]

Sounds like he is doing well and that’s wonderful!! Never heard of a bled score.

[lizzily in reply to Aprilbday]

Yes, doing great thank you. HAS-BLED is a means of working out your bleeding risk. His score would be lower without his glass of wine but there has to be some pleasures in life!!

[BobD Volunteer in reply to lizzily]

Actually that is not quite correct lizzily. A leading EP explained to me that it was an aide memoir of things to address BEFORE considering anti-coagulation. It should not be used to contra ChADSVASC but alongside. This is a common misconception I think we have all made.

[lizzily in reply to BobD]

Thanks Bob but I’m now totally confused! If you haven’t been on anticoagulants for 18 years shouldn’t you look at your risk of a bleed along side your stroke risk?

[BobD Volunteer in reply to lizzily]

It is a hard concept to grasp I know. The point is that doctors should look at each of the factors in the HASBLED and see what can be done about each. It is not a direct comparison for example if HASBLED score is 2 and CHADSVASC similar they cancel each other out. They don't and if you can deal the the HASBLED 2 then anticoagulation is fine.

[1Jerbear in reply to lizzily]

Hi Lizzily . I am A-fib and I have been in Eliquis for over a year .Today my wife hands me a paper that is called "Worst pills ,Best pills news " It points out a few things about this drug which are alarming. There is no antidote for this drug ,so if you have an emergency surgery or an accident there will be a major problem . So I definitely will talk to the doctor about getting me on something else . I just wanted to give you a heads up . There is also a test called CHADS SCORE which if you score zero you would be ok with out blood thinners .You can check into this also . Best wishes . Jerry

[cassie46 in reply to 1Jerbear]

First thing I would do is put the paper in the bin!!! Anticoagulants do not thin the blood - they prevent clots forming - if you bleed it takes a little longer to stop the bleed. Your blood is the same consistancy as anyone who is not on anticoagulants. Also they have a short life span that is why it is important to not to forget each dose. There should be no major problem if a major accident or surgery happens as long as the medical staff are aware you are on NOAC'S, I wear a wrist band alerting anyone treating me to this. Anyone in these circumstances would be at risk. My father was on Warafin and in his last years had quite a few major falls with severe bleeding. He was never given the Vit K antidote which is available for Warafin, always treated with pressure packs ect. I will happily take the small risk that goes with anticoagulants if it will prevent me from having a stroke.

Cassie

[lizzily in reply to 1Jerbear]

Hi Jerry, I also have AF and take Eliquis which suits me much better than Warfarin did. I read all about the fors and against of these newer anticoagulants before I changed over. They have been shown to be safe even though they don’t all have antidotes and as you take Eliquis every 12 hours it doesn’t take too long to get out of your system. See how you feel after you’ve spoken to your doctor but for me reducing my stroke risk was more important than worrying about having an accident. My husband scores 2 for his risk and probably should go back onto anticoagulants. I was just trying to do some research for him to help with his decision. All the best. Liz

[KMRobbo in reply to 1Jerbear]

Dabigatran (Pradaxa) is a NOAC with an antidote. An issue may be that whoever attends you in an emergency may not have it available.. I do not know if you can obtain the antidote to carry with you as I was only on Pradaxa temporarily.

[Hidden]

My take on this is OK, so the ablation has worked and that's good. But, has the left atria repaired itself over the 18 years or was it never damaged in the first place. This part of the heart is the area that is likely to release the clot which will find its way to the brain and bingo! jackpot ! a stroke.

The only way to find out if the left atria is normal or not is to have an echocardiogram. If it is still damaged, enlarged as mine is, then my view is take anticoagulants forever.

John

[BobD Volunteer in reply to Hidden]

Agreed John and if it had been me I would not have stopped in the first place!

[CDreamer]

From my understanding, the most recent advice is that stroke risk does NOT disappear, even after successful ablation and no noticeable symptoms of AF or AFl so my answer would be yes - anticoagulate - unless advised not by your doctor.

My husband is 84 and anticoagulated - the dose decrease I think at 80 to compensate for more fragile tissues and the risk of bleeding because of falls.

In our case - it’s me who does the falling - LOL!

[Hidden]

Apixaban is the safest of the new drugs also I think there is some research about putting elderly people on a lower dose especially if they have a lower body weight !

I take it and feel more relaxed taking it than not !

[seasider18]

With a mechanical valve Dewar was on Warfarin,

[lizzily]

Thanks everyone for your informative replies which confirm what I already thought. I’ve passed all you comments on to my husband to help with his own decision. Best wishes, Liz

[KMRobbo]

lizzily

These are the NICE Guidelines:

google.co.uk/search?q=A-C-p...

You will need to look up HAS-BLED on the web to understand that system

What I think I understood is that a SCORE or 3 or more is where "caution" with A/C is required but don't take it from me ( I am not a doctor) .

Best wishes

[Thomas45]

Just a note about anticoagulants and accidents / surgery. 3 years ago I fell at home and somehow cut open my lower left leg It bled profusely. I was in hospital for 3 days while they stemmed the bleeding. I had been taking Warfarin for several years and assumed they'd give me Vitamin K, but they didn't because I was in range, and keeping me anti-coagulated was important. Last November I had a grumbling pain under my ribs. It was a Saturday. I saw an out-of-hours doctor, and subsequently was told to report to a certain ward at my nearest hospital. I was immediately put on Vitamin K and Saline, and nil by mouth. 12 hours later I had been re-coagulated enough and the operation to remove my appendix took place at 2.30am on a Sunday morning. I don't take a NOAC as one of them, Rivaroxaban, didn't agree with me. (I am in permanent AF).

[Aprilbday in reply to Thomas45]

You made out pretty good I’ll say😊

[mjames1]

This recent study suggests he may not have to be on anti-coagulants.

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

In any event, a GP probably isn't the best person to guide you here. Seek alternate opinion(s), do your own research and come up with a decision that is best for your husband.

Jim

[doodle68 in reply to mjames1]

That is actually over a year old, this is newer ....

news-medical.net/news/20180...

''People with atrial fibrillation should continue to be treated even if heart rhythm returns to normal''

'

[fnurd]

I don't think this paper relates to patients who have had a successful ablation.

The three groups of people com pared were: those with ongoing atrial fibrillation; those whose records said that atrial fibrillation had resolved; and those who never had atrial fibrillation.

The "atrial fibrillation had resolved" group was very vague and appeared to comprise those who had not had a recent episode, and presumably those on medication. It is well accepted that these patients still have increased risk of stroke. Ablation didn't seem to feature.

[mjames1]

Doodles,

I previously posted a critique of the study you referenced which you never responded to.

Have you read the actual study here?

bmj.com/content/361/bmj.k1717

The study cited is for “resolved afib” which means in many cases very little, if

any long term follow up after an ablation. Given the recurrence rates of afib after ablation, the findings are not surprising.

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 followed up and showed no new events.

Lizzily suggests her husband HAS been followed since his ablation and has shown only ectopics.

So which study is more pertinent to Lizzily?

Thinners or no thinners is not a black and white issue and must decided case by case both due to the unique facts of each case as well as the risk management preferences of the individual.

Jim

[mjames1]

Furnd, I was writing my reply while you posted yours. We are in agreement. The study cited by Doodles does not seem pertinent to Lizzily's case. The "resolved" group had very little follow up so we don't know if afib came back or not. Lizzily suggests her husband has been followed with only ectopics.

Jim

[lizzily]

Wow folks, Thanks for the interesting debate. We are as sure as we can be that the ablation has been a success with only the odd ectopics and a recent ECG showed NSR. We’re very heart aware and feel confident that we’d have picked up any irregularities but sadly we’ve left our wonderful EP behind since moving house last year. It’s a new GP so we’re not sure how well informed he is. The appointment is next week so will continue reading and it will be fun to test his knowledge!!

[Jhcoop55]

While I would tend to agree with your GP, best get a second opinion from a cardiologist of EP. The risk of stroke once you have had AFIB increases with age and the guidelines would indicate that a 75 year old with prior AFIB is a candidate for anticoagulants. Remember, if you get a stroke from AFIB related events, those tend to be the most debilitating of all strokes. But, you need to weigh the other factors you noted.

I’m 62 and will stay on Pradaxa, likely for the rest of my life. Call it insurance to reduce the real risk of stroke.

[Aprilbday in reply to Jhcoop55]

Thank you

[cassie46]

Hi Goldie - I know things can happen and I am sorry to hear of your accident. it sounds as if you had terrible time. A member of my family in her 70's tripped and fell, she had a slight bang to her head but seemed alright. 3 days later she died with a bleed to the brain, she was not on anticoagulants. So we are all at risk, if this happened to me I would probably have gone to A & E to get checked out because I am on anticoagulants.

Cassie