when to take anti coagulants

[Tomred]

hi is there anyone on here with PAF that doesnt take anticoagulant i do not i am 60 year old male EP told me when he last seen me 1 and half year ago that id be on them at 65 my chads vasc score is 0 but surely afib is the same no matter what age i mean cant blood thicken and clot at 60 as well as 65 i know another woman on her first time discovering afib was put on anti coags straight away at 60 i dont know her chads score mind you but should i request anti coags from my GP or are they not given in uk except through EPs recommendation

[BobD Volunteer]

Some of us to believe that AF should mean anticoagulation. End of story. CHADSVASC is a guide not a law so you could ask your GP to consider if you feel strongly about it.

It is important not to think of these drugs as blood thinners, the so often used misnomer. They do not thin blood but they do slow down the clotting process. Blood doesn't thicken as you get older but generally speaking as we age we do become more at risk of clots forming for a variety of reasons. Being female also adds to the risk for reasons not everybody agrees with so there is always some discussion regarding the best way forward.

AF makes us all five times more at risk of stroke because the fibrillation can allow blood to pool inside the heart and form clots.

All that said there is also the fact that for every thousand or so people put on anticoagulants a very few may have dangerous bleeds so it is a balance of risk. As in fact is all life.

[Hidden]

I can understand your concern Tomred but the need for taking an anticoagulant is determined by a patients CHADsVASc score and if your Consultant has determined your score is zero then clearly it is deemed that there is no medical need and you are unlikely to be prescribed. You need to check the scoring yourself to make sure that all the elements that produce the score have been covered and that’s probably all you can do other than to try and persuade your doctor to change their mind. Even with a score of 1 they only say taking an anticoagulant should be considered. You need to bear in mind that taking anticoagulants is not without risk in that they can cause an internal bleed to have very serious consequences. If you are truly 0 then persuading your Doctor to change their mind is likely to be a challenge.......

[Hidden]

Just a thought, if there is any history of stroke within your immediate family, that may have have a bearing......

[Jumper]

I have only recently gone on to anti coagulants.. I am 74 . Over many years of PAF my CHADSVASC score was 0 as I had no co- morbidities. At 70 it became 1 it is now 2 . It rose to 2 because of my blood pressure rising to a level that needed treatment. The use of an anticoagulant at CHADSVASC 2 is because the level of risk at 2 is greater for stroke than major bleed. A major bleed requires hospitalisation. Major bleeds can be haemorrhagic stroke,internal bleeding within the stomach and kidneys each carrying the risk of death. Prior to 2 the risk of a major bleed exceeds the stroke risk. I saw no reason In using an anticoagulant prior to 2 for the above reason. Why risk a major bleed? The scoring system has been developed from statistics and the use of Anticoagulants at 2 is is the crossover point in risk. My progress through the stages and what to do has always been taken with the guidance and tutoring of my EP. I can fully understand sufferers of PAF taking anticoags at an earlier stage as it can be terrifying and I fully understand anyone taking anticoagulant prior to a CHADSVASC score of 2 if offered as it provides a comfort blanket but statistically it is not necessary.

[BobD Volunteer in reply to Jumper]

Statistics as we all know are dangerous things. There will always be exceptions! Three or four (at least)of our memmbers who were denied anticoagulants because their CHADSVASC score was zero or low subsequently had life changing strokes. It is also true that Hasbled which is often used as a contra to Chadsvasc is not a direct score but an aide memoire of things to address before giving anticoagulants. Consequently it would be wrong to say that there is a cross over point.

[Jumper in reply to BobD]

I am sorry to hear that members were refused anticoagulation therapy. That to me is not the purpose of the risk assessment scoring system. It is graded such that a discussion can be had between the patient and the their Consultant so that the patient can make an educated decision. That is why the terms 'should consider', 'recommend' are used. I assume they were below 65 and low or nil CHADSVASC.

There are outliers in all statistics and it is regrettable that it in hind sight the wrong decision was made by members so affected.

However, it also works in the opposite direction. The brother of a colleague who had PAF had a PVI done took the choice of anticoagulation, and had a brain haemmorage some months later. Fortunately, he has made a reasonable recovery but is now off anticoagulation and had to go through a Watchman FLX procedure, a mechanical left atrial appendage closure, to reduce the possibility of strokes from his AF.

Re crossover point I have to take issue with your comment. The risk profile of individuals is effectively a matrix of the various components that make up CHADS scoring system. Each type of anticoagulant be it warfarin or NOAC's have a varying bleeding risk. Warfarin being the highest.

The table below shows the varying risk with age and increasing CHADSVASC with Warfarin.

Annual Stroke/Bleed risk %

Age <65

No Therapy With Therapy

CHADS Stroke risk Bleed risk Stroke risk Bleed risk

0 0.7 0.3 0.2 0.6

1 1.7 0.3 0.6 0.6

2 3.5 0.3 1.2 0.6

Age

65-74

No Therapy With Therapy

CHADS Stroke risk Bleed risk Stroke risk Bleed risk

0 NAP NAP NAP NAP

1 1.7 0.5 0.6 2.4

2 3.5 0.5 1.2 2.4

75+

No Therapy With Therapy

CHADS Stroke risk Bleed risk Stroke risk Bleed risk

0 NAP NAP NAP NAP

1 NAP NAP NAP NAP

2 3.5 0.5 1.2 2.4

NAP - Not applicable

Note Women are always 1 value above men so no woman has CHADSVASC score of Nil

You can see that the crossover point is most clearly shown aged 65 – 74 and CHADS of 1 where the bleed risk with therapy is higher than the stroke risk without therapy. It also shows the definite advantage of taking therapy with CHADS of 2 of any age group. The benefits are marginal for the CHADS score of nil and any benefits of stroke risk reduction would reduce with decrease in age.

However the table gives some insight to why there should be discussions between the patient and their consultant and why the terms ‘consider’ and ‘recommend‘ come into play particularly where CHADS 1 is concerned.

NOAC's have a different profile of effectiveness but the principle remains.

We are all affected by our own personal experiences , ( I have to count myself here ) but one must be aware that the application of an anticoagulation with low CHADS score 0 and 1 has implications as the bleed risk is only for serious major bleeding including intracranial bleeding, and/or other bleeding requiring hospitalization.

I read the forum contributing when I consider it important. In this particular case I feel there is a tendency amongst contributors to sometimes down play the risks of major bleeds and suggestions and also desires that anticoagulation should be used more aggressively at the lower CHADS scores of 0, particularly, and 1 without full consideration of the risks involved.

[Lizty]

For some reason women are more of a risk of stroke. If female, you already have a chad score of 1. At 65, I had a chad score of 2... one for being female and one for being over 65.

[BobD Volunteer in reply to Lizty]

In my original post I did mention that not everybody agrees with this Litzy and I have heard several experts comment that this extra one should perhaps be ignored.

[Lizty in reply to BobD]

Interesting Bob..... I must admit I felt a bit disappointed as I was just 64 and a half when I had my diagnosis! As I have paroxysmal AF with no other medical issues, I think that adds another level of uncertainty. My EP said that he could not tell me why I had this condition.... mostly because research has not yet discovered why relatively fit people develop such arrhythmias. However, he did tell me that more women, statistically, die of AF related strokes. I guess that we are dependent upon the most contemporary research and that will be updated over time. For the moment, the controversy over treatment will probably continue!

[simeisam]

I was told back in May I had AF, having popped in to AE as I couldn't measure my pulse properly as it was all over the place, has happened 4 times in 5 years. I'm 67, fit and have no underlying conditions and take no meds of any kind. NHS uses the HASBLED scoring table as well as CHADS2, I scored 1 on both. I was told I was low risk and offered anti coagulants but declined until I could better understand the condition and especially the risks of the DOAC anti coagulents. My GP is in no hurry for me to start them. Will be unlikely to get in to see a cardiologist in the NHS to discuss my issues till next year I am told as the backlog is dealt with so will try the private route in the hope their backlog list is a lot shorter. There is an interesting video on YouTube by Dr Sanjay Gupta the York cardiologist about AF stroke risk which is worth watching.

[secondtry]

I am 67, male, no comorbidities and don't take ACs. My rationale is as per Jumper's reply above. I do major on lifestyle changes to reduce the risk.

[Bayonnejoe]

I'm the no anticoagulant horror story. I am a stroke victim, the other side is, I guess, the person on anticoagulation who has a serious bleed. My CHADSVASC score was zero, maybe 1, some eight years ago, after a lot of discussion with a cardiologist, having just been identified with intermittent, paroxysmal, AFib, he said I could get by on aspirin therapy. Well, my AFib deteriorated unbeknownst to me or my GP and short story, my heart kicked out a big clot. Boom. Lost my left lower peripheral vision. I was lucky. I ended up at Johns Hopkins where they explained just how lucky I was. You can look up the stats, they aren't pretty. I'll take the bleed risk on anticoagulation any day. The lesson for me in retrospect, beyond making sure your cardiologist is competent, is making sure your CHADSVASC is accurate. And make sure your AFib isn't moving, as AFib often does, to a persistent state. Mine was asymptomatic so I was easily self-deluded into believing otherwise and my GP wasn't tuned into it. Btw I'm mid-60s, male. None of this is easy, and I wish you the very best in whatever you choose, in consultation with your cardiologist.

[jwsonoma]

I will add the same thing. I had a stroke in my late 50s that was later determined to be caused by PAfib. I quickly regained my ability to read. My CHADS... score would have been 0 at the time.

So your score is zero until you have stroke, which are often permenantly debilitating, You get 2 CHADS pts for a past stroke. Then they recomend anticoagulants if you are diagnosed with AFib. A sort of closing the barn door after the horse has left sort of thing.

I am on Wafarin which slows down the coagulation mechanism proportionally to the amount in your system. There is a target range (INR reading) where it is therapudic in preventing AFib caused blood clots on the low end and unnecessary risk of bleeding on the high end. I have a self tester I use at home and test frequently. Green veggies have varying amounts of Vitamen K which is the antidote for Wafarin so if you eat a lot of veggies it is a work to keep in range.

If I am going siking, rollerblading, or mountain biking where there is a risk of a fall I make sure my reading is on the low end of the range. Otherwise I keep it in the middle. It works for me.

There is a lot of great info on the board. A lot is anecdotal but it is like haveing 20 friends who went through the same thing.

Cheers

[Blavet]

Hi Tomred. Look at chadsvac.org. A male being 60 with no other co-morbidities shows a score of 0. Take a look. It should clarify things. I had PAF for over 14years and my score I think was 1 for being female but didn’t need coagulating. Had a ablation in 2006 and still free of it so far. Hope this helps

[CDreamer]

Interesting replies which I believe highlights the issue of choice and what influences our choices, which is rarely based upon data or logic, no matter how we like to kid ourselves.

We make choices based upon our emotions, beliefs and fears.

What is highlighted in this thread is who is more scared of bleeds and who of clots.

I don’t think that there is a right or wrong answer about anticoagulation, just right or wrong for the individual but the question I would pose:-

Is it ethical to deny prophylactic treatment to an AF patient who IS afraid of AF induced stroke who seeks that treatment?

It seems to me that this is issue for the original poster.