Family history of stroke

[Slattery]

I have a Chade score of 1, no other health problems. My older sister had a TIA Attack last night and I have another sister who had a massive stroke years ago. My question is should I be on anticoagulants due to family history?

[BobD Volunteer]

In my view yes. What is your one score for? I think one should take a famiay history into consideration with this. A score of one makes anticoagulation optional where as two it is advisable. Factor in family history and I would say you should even with a score of 0!

[Slattery in reply to BobD]

The 1 score is for my age of 71

[Hidden]

Your CHADS2VASC2 score is 2, based on your age 70 and female sex. This makes you a potential candidate for anticoagulant (AC) treatment.

From what you have said, it is not clear that your sisters’ stroke/tia history is due to AF. Not all strokes are ischaemic, and not all ischaemic strokes are due to AF.

I don’t know whether a family history of AF and ischaemic stroke is considered a factor in deciding about ACs. If it was, then a diabetic aged 30 with AF and a family history of AF related ischaemic stroke would be a candidate for ACs.

[BobD Volunteer in reply to Hidden]

Many people Oyster, myself included feel that AF should mean anticoagulation regardless of CHAD or CHADSVASC except in extreme circumstances. Of course this is not policy merely opinion.

[Slattery in reply to Hidden]

Being a women is no longer a Chad score of 1.

[Kaz747 in reply to Slattery]

I have seen a paper arguing that female sex is a modifier rather than a risk but I haven’t seen anything official that has changed in the CHADSVASC score. If you have any info on this I’d be happy to see it.

I’m a 54 yo female who had mild hypertension and my EP said even though it appears fine now the fact that I have had blood pressure problems still counts (and I had very high blood pressure & preeclampsia with my pregnancies).

I’m happy to be on an anticoagulant as I have a family history of strokes and TIAs - grandmother, mum (TIA), Aunty and Uncle.

Doctors also found a blood clot in my heart last year when they were going to do an ablation so I know for sure that my body is very capable of forming clots. That was when the seriousness of the risk really hit me. I’ve often said if I have a stroke and it kills me, fine (well not really) but I don’t want a stroke that I survive that leaves me severely disabled, like my grandmother. A tablet a day is a small price to pay to reduce that risk.

[Hidden in reply to Kaz747]

Slattery is right in as much as the Australian guidelines have dropped F=1 from CHADS2VASC2. See my post below.

The China AF study seems to support this.

[Kaz747 in reply to Hidden]

Thanks Oyster. So I see. The new Aussie guidelines came in around the time I was put on anticoagulants. My EP won’t be taking me off them any time soon (if ever).

[Auriculaire in reply to Hidden]

Japanese study too.

[Hidden in reply to Slattery]

researchgate.net/publicatio...

This study from China supports the sexless CHADS2VASC2

And recommendations in Australia have changed to drop female =1, as Aqua_1 has pointed out below.

mja.com.au/journal/2018/new...

[Auriculaire in reply to Hidden]

And that makes a good deal more common sense than the present scoring system in which there seems to be no discrimination between real comorbidities such as diabetes, hypertension and CHF and general categories such as age and sex where there can be very disparate genetic and clinical variation.

[Hidden in reply to Auriculaire]

A good argument in favour of personal, or individualised medicine, where resources allow it.

[Auriculaire in reply to Hidden]

You get a bit more of that here in France. My GP appointments are never rushed and I can get an appointment with my cardiologist fairly quickly even for a routine checkup. Both seem to think I do not need anticoagulation even though I have a score of 2 for age and sex. I am not sure if that is because the ESC guidelines changed recently or because they are taking my general health into consideration or both. I am taking nattokinase, curcumin and bromelain . There are no strokes in my family that I know of though my father died of a heart attack at 40. My worry about anticoagulants is not bleeds but other side effects as I do very badly with drugs in general . I tried Pradaxa but could not get on with it.

[Hidden in reply to Auriculaire]

Why are health services and schools so much better in France than in the UK? Is there more to it than funding and staff retention?

[Hidden]

I’m inclined to agree with BobD. Whilst for some, interlectural debate may have its place, I’m not sure taking the risk of getting it wrong and perhaps having to be fed via a straw as a consequence is the way to go.......purely a personal opinion

[CDreamer]

I would not rely on CHADS score - it’s only a guide for risk. I’m with Bob, wasn’t always but the evidence I think is now enough to say if you have any sort of AF then AC’s are advisable. The older you are and the longer you have had it, then to my mind the higher the risk. I’ve had 1 minor TIA on AC’s.

The talk at Patient’s day was that the only reason that CHADS score of 1 or 2 were advised to take AC’s was because there had been little or no research done on population suffering AF strokes with a 0 score. Food for thought.

[Hidden in reply to CDreamer]

I’m confused, I thought the evidence underlying the CHADS2VASC2 based recommendations was very robust. It may be very difficult to find sufficient numbers of AF patients with strokes despite score 0, to draw any conclusions, but it is hard to imagine that the guidelines will be changed any time soon, based simply on speculation, without that evidence. But guidelines are just guidelines, and I’m all in favour of personalised medicine.

If you have the time, I would be interested to see a link to the evidence you mentioned in your first paragraph.

[CDreamer in reply to Hidden]

Expressed based upon comments made by one of the presenters at the Patient’s Conference at Birmingham - I haven’t got links.

My understanding of what was said was that the figures on efficacy of ACs at reducing AF related stroke were based upon CHADS score of 2 or more. As there were no large scale studies of efficacy of ACs to reduce AF related strokes with a profile of less than 2. What was suspected was that everyone with AF would benefit from being on ACs and what was needed was hard data.

The general consensus seems to be that CHADS is the best tool currently available to calculate risk but that doesn’t really help the individual.

From what I have observed fear drives decisions here - are you more frightened of AF stroke or bleeds? Statistics are numbers, they may help doctors to decide what to advise but speaking personally don’t help an individual.

[Hidden in reply to CDreamer]

Thanks for that. I am all for challenging the status quo and received wisdom in life generally. I feel fortunate to have a relationship with my GP which allows me to receive treatment which reflects that. But I don’t think the era of individualised medicine has arrived generally in the NHS. Until new theories are robustly tested, I’m not clear that anything in the guidelines should change.

From a purely personal point of view, I am strongly in favour of anticoagulation. I remain unconvinced that DOACS are as effective as warfarin.

[Bagrat in reply to CDreamer]

Exactly CDreamer

[Auriculaire in reply to Hidden]

I read somewhere that most of the input for CHADSVASC came from Scandinavian populations in particular the Danes as they have a comprehensive national patient tracking system. Looking at some data in a study linked to by an article from a clinic in America about why CHADSVASC might not be as good as it's cracked up to be ,it was clear that the Scandi stroke rate was higher than all others except Hong Kong and the Danes were higher than the Swedes. Hence the doubt over whether it is universally applicable.

[CDreamer in reply to Auriculaire]

Interesting background, thank you.

[Auriculaire in reply to CDreamer]

The American article was linked to here.

[wilsond]

I would say yes. I was in the process of fighting my previous to to get AC'd when I h ad a,TIA and hospital put me on ,especially when they asked family history( mum and grandma had fatal AF stroke,dad and his dad both had several strokes.)

I feel much happier on them. I was told I was 1 by previous rather arrogant GP just because I'm female,but actually was 2 as have high blood pressure,even though medicated still.counts.

Are you sure you are 1? Even so I'd still push for AC.

Lifestyle changes have made a huge difference to me too.

Best wishes and hope your sister is ok. Xxx

[Slattery in reply to wilsond]

I have an appointment with an EP APRIL 5th to discuss family history. I will do whatever it takes to avoid a stroke.

[icklebud99]

I think you absolutely should, you need to discuss with Cardiologist, EP or GP and push for this. Now.

[Aqua_1]

There are references re the sexless chadvasc score in the attached.

mja.com.au/journal/2018/new...

Note these are the Australian guidelines.

[Hidden in reply to Aqua_1]

researchgate.net/publicatio...

This paper from China supports the changed Australian guidelines

[Hidden]

Anyway Slattery, regarding your question. Given that your CHADs score is 1, in the UK, the advice (from non-commercially interested sources) is that you should consider taking an anticoagulant. Generally, the advice that I have heard from experts on the subject is, provided there is no evidence of risk of internal bleeding, it’s better to take an anticoagulant. I’m not qualified to comment on to what degree if any, close family issues may add to your potential risk, but common sense alone suggests that anyone in your situation would be wise to seriously consider taking an anticoagulant. Certainly you should seek professional advice so that you can make your decision based on facts which are derived from reliable sources. It would be interesting to know what you finally decide to do. Good luck.......

[Slattery in reply to Hidden]

Thank you all for this valuable information. I will let you know what I decide to do.

[Slattery in reply to Hidden]

I am going on anticoagulants. Thank you for your experience.