Anticoagulant Uptake in US

[CDreamer]

I have noticed that the Anticogulants seem to be much less used in the US for those with AF than in Europe, despite the evidence showing their efficacy of their prophylactic value of preventing AF induced stroke.

It seems this is now also troubling EPs in the US, as this article notes:- The data are "sobering and eye-opening," said Kalyanam Shivkumar, MD, a cardiac electrophysiologist and professor of medicine at the University of California, Los Angeles. "We're stuck with this big challenge," the gap between "what medicine can do and what it actually does" when evidence-based interventions fail to gain traction in everyday practice, he said in an interview.

This follows a 1:1 mailing to known AFibbers with information about the importance of Anticoagulation and where only 10% responded.

medscape.com/viewarticle/93...

[BobD Volunteer]

And they still think aspirin helps.

[Daver112 in reply to BobD]

Do you work for Medscape.com Bobby D ??

[Coco51]

I wonder if their stroke rate for AFibbers is significantly higher than ours? Would assume it must be.

[CDreamer in reply to Coco51]

Coco - that is a very interesting question and I can’t find much on that which is dated later than 2008-9 and most of the research I have found is Europe based.

This is the US AFA for clinicians information heartrhythmalliance.org/afa... but no stats there.

An Irish study based on NDublin population quoted a US figure of 15-20% of all strokes recorded in US were AF related - but that study was dated 2009.

This may be of interest journals.plos.org/plosone/a...

[Kaz747]

Is that to do also with their medication costs?

[CDreamer in reply to Kaz747]

I wonder? There was a lot of class actions taken out against Pharma companies back in the 1990’s/2000’s, especially against the NOACS when they were first available as the recommended dose was out for older people so I also wonder if there is a reluctance within the general medical community to recommend A/Cs for fear of litigation?? I’d be interested in views from across the pond?

[Nugger in reply to Kaz747]

$500 a month & only $70 in Uk

[CDreamer in reply to Nugger]

That’s madness! How do people afford healthcare in the US? We have a standard prescription charge - no idea what it is now circa £15?? as over 65’s receive free prescription meds.

We had to pay for months supply for my husband‘s A/Cs when we we were caught out as flight home was cancelled in Feb but that was 40Euro. If I had to pay for my meds I’m not sure I could afford them as I know the cost would be upwards of £150/month.

[Nugger in reply to CDreamer]

Prescriptions in England are free at age 60, been free to rest of Uk for years.

$70 is what the NHS pays, I was quoted a price of $114,000 for a 5 minute cardioversion, here in the US

[CDreamer in reply to Nugger]

I just checked - you are correct thank you - under 16 or over 60 - no charge & £9.15 per item for everything else.

[Kaz747 in reply to Nugger]

In Australia I pay A$41 for my anticoagulant which is US$29 or £22. For pensioners and those on welfare it would be A$6.60 which is US$4.75 or £3.50.

[GrannyE in reply to Nugger]

Good grief. It is a wonder that anyone can afford healthcare in the US. We are so lucky here in the UK

[FancyPants54 in reply to GrannyE]

We have been. I'm not at all confident it's going to stay that way much longer.

[sotolol in reply to GrannyE]

We are I just sent an email to my cardiologist and her secretary saying just that. God bless the NHS. They saved my granddaughter when born because of their quick thinking. I ended up in same hospital with AF. LOL. The same time but couldn’t tell my daughter.

[seasider18 in reply to GrannyE]

Apart from the waiting lists.

[cuore in reply to Nugger]

Wow! I live in Metro Vancouver, Canada which is right near the US border. I am now priced out of travelling to the US, and to think I lived in the US for over seven years to get two degrees not worried about my health then. Now I am priced out of crossing the border insurance -wise or emergency -wise. $114,000 is more than insane.

[CDreamer in reply to cuore]

I think that may answer my question to you below.

[Ren912 in reply to Nugger]

Unbelievable! $0 in Ontario, Canada for cardioversion and I’ve had several. Meds cost $4.11 per prescription after $100 per year copayment.

[belindalore in reply to CDreamer]

Yes it is madness CDreamer. Unlike in your country there are a lot of different insurance plans here in the USA and you basically get care or not depending on how good your insurance plan is. We say someone who has really good insurance has a Cadillac plan. There's HMO which is what I can afford but severely limits you to what Drs you can see. Then most people who have the Cadillac plans have PPO in which you are able to see whatever Dr you choose. The USA does have Medicaid for those who are in poverty and cannot afford insurance. Covered by the government. It's gotten to be some Drs won't accept Medicare (government backed insurance we get when we turn 65) because it sets pay limits for Dr and hospital services. Drs don't like that and it takes forever sometimes for Medicare to pay and it's lots and lots of paperwork for all the different insurance plans any one Dr accepts. The Drs have high overhead because they have to employ so many people to keep track of all the different insurances. They all pay out different amounts for the same service. So it is total madness. Medical care in this country has really become profit over patient. The insurance companies basically rule what Drs do here. The big pharmas rule over the insurance companies. And big corporations who have stock in the pharmas and insurance companies expect them to turn big profit so they can get rich. Sad but true. I am old enough to see how medical care has gone from patient to profit in the USA. It's really disheartening. People die here from lack of insurance. Oh they can still go to the emergency department in the hospitals but they usually get a "bandaid" and sent on their way. I know your system isn't perfect. I've seen people on here complain about your NHS. You pay into it same as we pay into Medicare. But Medicare is only for people 65 and over and for those who have special needs. But all in all it seems like your system discriminates less against those that are poor than here in the USA. Obamacare was supposed to be the answer to people who couldn't afford healthcare. Biggest joke ever. I laugh at the commercials we have on TV advertising the wonderful treatments for cancer and different ailments. Yes they are wonderful if you have that Cadillac insurance or some other way to pay for it. One last thing the drug companies spend tens of millions of dollars on TV ads to hawk their drugs. How many people could be helped by all that money. Yes madness.

[Nugger in reply to belindalore]

I second that! Then there’s teeth & eyes to pay for tooooooo

[belindalore in reply to Nugger]

Oh I forgot those😛

[CDreamer in reply to belindalore]

I’ve just had to get new glasses and the cost of them is jaw dropping, ditto teeth. Teeth and Eye Care are only covered for children and finding an NHS dentist is almost impossible and then there is so much not covered and you still need to pay as it is subsidised, not fully paid for. My optometrist has just stopped covering NHS sight tests for exactly the reason you stated - cost of admin filling in the forms and delays in payment.

Our system is quite complex and somewhat confusing and rather reliant on where you live.

[belindalore in reply to CDreamer]

Wow. Well it seems healthcare is at an all time low nowadays no matter where you live. As the saying here goes -them that has it gets it and them that don't, don't. Sad.

[pusillanimous in reply to CDreamer]

In South Africa we have Medical Aid Societies - it is not medical insurance but a rather complicated system relating to private medical care, without boring you with that, my Xarelto is priced at slightly over R1000 per month, of which the Society pays two thirds from my monthly subscription and . Given that there are R22 to one pound Sterling,it is not too expensive here. R represents Rand , the South African currency.

[RxMe in reply to CDreamer]

I pay $47.70 (USD) per month for Eliquis through my Medicare Supplement plan...plus the monthly premium, of course!

[Madscientist16 in reply to CDreamer]

We can't afford it. We pray that we don't get sick or pray for a job with good insurance. Cost of healthcare and insurance is always a big topic before elections here in the US.

[CDreamer in reply to Madscientist16]

That must be very worrying for you. I know we can no longer afford to visit the US because of the prohibitive costs of insurance, even if we had the freedom to visit. Go well.

I know we in the UK are undergoing change by stealth and hope and pray we do not follow US down the health privatisation route, however, there are already signs that we are on that path, unfortunately we don’t seem to be having the debate because so few people realise it is already happening. COVID seems to be accelerating the process.

[Brad43]

I'm in US, and I've been on anticoagulants for several years. As far as I know, it's pretty much standard for anyone with AF to take them. I'm surprised to hear that you think we don't.

[CDreamer in reply to Brad43]

That’s not what the article indicates and it has been my observation that as Bob, said, aspirin is still recommended.

[Brad43 in reply to CDreamer]

OK. I read the article. I suspect they know more about it than I do. But I've gone to two cardiac practices in the last eight years, plus discussed it with at least one other doctor, and all indicated that anyone with AF should be on anticoagulant. I know that my own EP prescribes it for all of her AF patients. Many years earlier, I was told that I should take aspirin, and I did so for a few years, but that was debunked a long time ago. If people here in US are still taking it, I guess the word just hasn't gotten around yet.

[Herogenus]

I had a TIA last October... the day after I had a 13 hour bout of a-fib ( I've had paroxysmal a-fib for 12 years) Hospitalised for 4 days & after an MRI I was put on eliquis 2 x per day. The horse had already bolted in my case. This is France.

[CDreamer in reply to Herogenus]

Was there a reason you weren’t recommended to be on anticoagulants prior to the TIA? I don’t know much about the French system, only the UK & Spanish, which seemed excellent.

I was on A/Cs before and after ablation, then no AF for over a year so my EP - very reluctantly, agreed I could come off them as long as I went back on them aged 65. I also had a TIA a few months later and couldn’t get back on them again quick enough!

The cost of A/Cs pales into insignificance compared with the costs of caring for someone with a major stroke!

[cuore in reply to Herogenus]

There must be more to your story because France has lead the world in AF procedure. Specifically, Dr. M.Haissaguerre and his team developed in 1994 the ablation technique which the world now follows. The LIRYC institute in Pessac, France was recently built to bring all heart specialities under one roof to research heart disease, definitely AF.

Personally, I have gone to Pessac, France from Canada for my three ablations to now be 15 months AF free.

Granted the topic is anti-coagulants, my Pessac EPs (outskirts of Bordeaux), always made sure I was anti-coagulated. I have high esteem for France because without FRance I would be in permanent AF today.

[CDreamer in reply to cuore]

Was there a particular reason you travelled to France for Ablation? What is the situation in Canada regarding anticoagulation recommendations and treatment?

[cuore in reply to CDreamer]

Had I remained in Canada, specifically Vancouver, B.C. I never would have been able to return to sinus. For my third ablation, I was one of the most complicated cases at the six month persistent stage (defined by the first ablation). For this third ablation, Vancouver, B.C. gave me 60% success: Bordeaux 85% which turned out to be true. Bordeaux has world-class EPs and state of the art mapping systems. They have built LIRYC , an institution bringing together under one roof all heart related specialists to try and solve this AF mystery.

In the AF field, Vancouver has inadequately trained cardiologists who inadequately train GPs, (an inferior cardiologist trained my GP), plus NOT the latest mapping systems, and horrific waiting times. Rather than being properly treated at the paroxysmal stage, I was allowed to fall into persistent and was being kept in persistent to reach long-lasting persistent, and probably permanent which has happened to two friends of mine. I paid for all three ablations myself, and was pleased to do so considering the results.

Anticoagulation guidelines in Canada are the same as those in the U.K.

[CDreamer in reply to cuore]

Hi - thanks for your reply. There are a few people on this forum from Canada and all report similar difficulties in accessing good treatment for AF, especially ablation. It seems that Healthcare is now a Global Industry with people travelling to access good care. How disappointing that it’s not accessible in your own country.

My cousin lives near Montreal and had a quadruple bypass some 4-5 years ago and described excellent care but I expect that procedure is more common. At least she seems to have done well. Best wishes

[cuore in reply to CDreamer]

My observation is that whether in the East (Montreal) or whether in the West (Vancouver), life threatening heart conditions receive excellent care. Since AF is non-life threatening, the area receives neither adequate funding nor adequate training for clinicians.

The East (Toronto) has a superior AF mindset with shorter wait times for an ablation , perhaps better mapping, and a greater number of experienced EPs . In British Columbia, the most western province, it is illegal to have any private clinics (although presently there is an on-going 3 year court case to remove restriction) resulting that there are no private AF clinics and no availability of private consultation as an avenue to speed up the ablation road.

Our medical system is "free" in B.C. But, "free" has no taste when you are placed on a path to permanent AF when you can be in sinus rhythm. Due to France, I am now enjoying 15 months sinus, granted I have had one 5 hour episode when I tried to stop Propafenone.

Thank you for your wishes, and I do wish you the same as I have followed your AF journey.

[GrannyE]

Absolutely. I would think that the cost of preventing a major stroke is chicken feed compared to that of treating and nursing someone with one. There is def a cost benefit in giving anticoagulants.

[Bayonnejoe]

I'm in US. 66 years of age. Understanding disparities in health care here would require a massive book. Quality? Some of the best teaching and research hospitals in the world juxtaposed by rural and inner city care that is akin to the third world. Costs that range from fully covered or near so, for indigents, military vets and over 65s, to bankruptcy producing bills for the average worker coupled with prohibitive private insurance premiums. My AFib was treated by an incompetent, in retrospect, rural provider with aspirin, resulting in a stroke with partial vision loss, to now being seen by doctors at Johns Hopkins who immediately put me on apixaban. I have a Medicare Advantage plan that is excellent, inexpensive and the Eliquis costs me $10 monthly. I've seen it cost $500 monthly for those with poor insurance under 65 years of age. My daughter is an expat in Ireland. She has their NHI, but buys a private policy owing to her lack of faith in their public system and long waits. Which we have here too, even with the best insurance. I have no answers. Health Care is problematic everywhere it seems.

[Sassyspy]

As much as I hate the hassle of taking warfarin, there's nothing else I can take with a mechanical heart valve.

The silver lining is it only costs me $1.20 with my Advantage plan.

[tunybgur]

...and Warfarin is so cheap. I guess anything that doesn't make big money for the US pharmaceutical companies is not of much interest?...sorry, am I being unfair?

[CDreamer in reply to tunybgur]

The 2 reasons I would choose DOACs over Wafarin - apart from the convenience - only affective if you can stay in therapeutic range and the need for frequent INR testing to ensure you stay in range and that people on DOACs have been shown to be have fewer brain bleeds than Wafarin.

[tunybgur in reply to CDreamer]

I'm pretty stable on warfarin and only have an INR check every 3 months, but it's the cost I was comparing, I think the DOAC's are more expensive but by how much in the US I don't know....

How do you know about the brain bleeds? as a user I'd be interested in any background info on these meds.

[CDreamer in reply to tunybgur]

There have been numerous studies over various populations in the last 20 years and all seem to agree that the incidence of brain bleeds in people anticoagulated with DOACs v Wafarin are lower in the DOAC group and they are different type of bleed. Because I have a neurological condition I watch the neurology studies as much as the AF/heart studies.

Just one article :- acc.org/latest-in-cardiolog...

There have been studies in various countries and so far, I’ve not seen one study that contradicts the results quoted in this article.

I think Nugger makes a good point that all anticoagulants reduce stroke risk, they don’t prevent stroke and that we always need to balance risk:benefit between clots and bleeds as doesn’t matter which causes a stroke - the outcomes are just as devastating.

[tunybgur in reply to CDreamer]

Agreed, they can both be devastating, but perhaps a haemorrhage is easier to treat than an embolism, or am I being too simplistic....probably?.....I'm not a doctor.

[CDreamer in reply to tunybgur]

My brother was treated for 2 bleeds which required a craniotomy. 1st line treatment was watch & wait to see if it stopped on it’s own which it didn’t. Thankfully it was successful.

My understanding is that there are drugs which can help bust clots, aspirin being one, but treatment for either bleed or clot always carries risk.

[Nugger]

Just remember that it doesn’t prevent stokes but reduces them by 50/60 percent, allegedly

[dmjtanner]

My doctor put me on Eliquis immediately here in the states when I had my first afib attack. I didn’t want to go on it at the time, but he insisted. I am on Medicare and my secondary is Tricare because my husband was 24 years in the service. I get a 3 month supply from a mail order pharmacy for $29.

[Jacqengle]

Which mail order pharmacy?