Phone call from EP

Just received a phone call from my local EP who has received the letter from the St Bart’s EP requesting a referral to an opthalmologist (to see if there is a significant risk of another subconjunctival haemorrhage if I take an anticoagulant -this occurred when I took one 9 months ago; I have to take an anticoagulant if I am to have an ablation in around 6 months).

The local EP said that he thought the risk of another was only slightly higher than his own! However he offered no explanation for this- to me-highly dubious assessment of the probability. He also said that he thought there was no need to see an opthalmologist; however, when I insisted, pointing out this was the recommendation of the St Bart’s EP, he agreed to refer me but said this would slow things down.

I didn’t have much time to talk to him, but I did say that I was only getting PAF once every 1-2 months. He said that was good, but was still “too often”; it could still progress to permanent AF, although this could not be reliably predicted. This was not really what I wanted to hear. I was hoping that the PAF might be controllable and that the ablation could be put on the back burner. No such luck.

[BobD Volunteer]

I'm sure you will have heard many times AF begets AF ..

[Hidden in reply to BobD]

I have, but I thought-probably naively- that as the frequency of the PAF hasn’t increased in fact -maybe decreased slightly-that I might be able to defer the ablation. Also, the St Barts consultant was quite upbeat. Although I’ve had the PAF for 9 months or so, it still feels as if it’s slightly unreal- as if I will wake up and discover its all a bad dream.

[Hidden]

Thanks for your reply. Couldn’t find the HATCH calculator however.

[Hidden in reply to Hidden]

You might find this interesting

core.ac.uk/download/pdf/826...

[Hidden in reply to Hidden]

Thanks. I have downloaded this and willl read it when I get home.

[Alessa69 in reply to Hidden]

Neither could , I also wanted to check my Hatch score

[Hidden in reply to Alessa69]

This article is fairly good:

afibbers.org/atrial_fibrill...

[Hidden]

Not clear why you feel your local EPs assessment of the probability of you having another subconjunctival haemorrhage (SCH) is highly dubious. I had several SCHs before going on an anticoagulant (warfarin) and thought nothing of them. I have also had them since ACs. I wasn’t surprised they were a little worse. I have always attributed them to having an active outdoors sort of lifestyle.

I’m surprised your Bart’s EP thought you should be referred to an ophthalmologist, not at all surprised he didn’t want to refer you himself. It will be interesting to hear the outcome.

[Hidden in reply to Hidden]

The St Barts EP did not have to be persuaded about the referral to an opthalmologist. He agreed that this was appropriate.

Why do I think the local consultant’s assessment is dubious? For two reasons. Firstly, his comment doesn’t suggest that he has considered the relevant probability, or even what the issue actually is.

He said that if he and I both took an anticoagulant, then my risk of a SCH would be only “a bit more” than his. However, the concern should not be simply with the risk of having another SCH, but with bleeding in proximity to the eye (possibly on the brain) which would be potentially dangerous.

Furthermore, what is relevant here is the probability of suffering bleeding in proximity to the eye *given that* the patient has already suffered bleeding in that region shortly after taking an anticoagulant; in other words it’s a conditional probability. Nothing he said suggests that he has considered that probability.

The second reason, related to the first, is that an experienced GP has said that he thinks there is a risk (and on that basis has recommended deferring an anticoagulant) and another consultant feels that caution and further investigation are warranted.

[Blavet in reply to Hidden]

This type of vitreous bleeding seems to happen more when people are transitioning from warfarin to these new NOACs like Rivaroxaban or Apixaban. It is important to be assessed by an ophthalmologist to make sure there’s no other underlying problem there.

[Hidden in reply to Blavet]

Are you thinking of a vitreous haemorrhage? This is quite different from a subconjunctival haemorrhage.

nei.nih.gov/health/vitreous...

[Blavet in reply to Hidden]

I should have said Subconjunctival. Just out of interest we’re you transitioning from maybe Warfarin onto a NOAC

[Hidden in reply to Blavet]

No, it was before and after warfarin (I have edited my post above).

I have also had a vitreous haemorrhage while on warfarin and did get that looked at. I had a sudden onset of a lot of red blood cell floaters in the field of vision but no loss of vision. Everything was fine, and 5 years later most of the floaters had gone. After a recent cataract extraction I seem to have a fresh lot but its early days and the ophthalmologist isn't concerned.

[Blavet in reply to Hidden]

My PAF started after a RF ablation for SVT way back in 2005 it was after this that I had PAF and this continued until 2016 when I had my pulmonary veins isolated in a cyroablation. This was successful, so far no AF but since December I’ve been having a few problems with fast heart rates, they say it’s just sinus tachycardia. Dr has prescribed Diltiazem but I haven’t started it yet as I feel my hearts settling down. I myself was never on an anticoagulant or a NOAC except for a few months before my ablation. I hope you get things sorted out.

[Hidden]

I have taken medication for hypertension for 5 years or so. My blood pressure is normal *with medication*. I don’t have any of the other things listed.

[secondtry]

You don't say what medication you are taking for the AF or your QOL. From what you have said, I would try medication/lifestyle/supplements first to see if you can stop the periodic AF episodes before an ablation is undertaken.

I had 9 episodes in a month and was offered an ablation by two cardios and an EP but agreed we would try Flecainide at a medium dose first and it has worked for 5 years.