I'm being a right ditherer today, in fact I have been all week. Now that I no longer have atrial fibrillation, should I give up on the anticoagulant? I was continuing with it because it had kept my migraine at bay for two years now. (That's apart form a period after my ablation).
However, I knew that I had had a couple of very small bleeds into my left eye and when the trainee surgeon examined my eye before the operation last week, she mentioned bleeds to the surgeon. He said something to the effect of 'don't let's bother with that at the moment', which was fair enough.
A couple of months ago someone asked if it was best to discontinue with the anti-coagulant before an eye operation. I didn't get a chance to find out and I'd put it down on the form so thought it was probably alright. However, when they started there was some talk about 'she's on Apixaban' and I got the feeling it was making it more difficult for them.
I will ask at my appointment next week whether he thinks I should stop taking it and about the bleeds too. I can see a circle which is the air bubble they put in and it is now down to the size of a jam jar lid. Today, I can also see a black dot bobbing around which is the size of a pea. I'm guessing this is blood.
Anyway, I've cut the Eliquis down to once a day. The reason why I've been dithering is because I know that migraine increases the risk of stroke but the Eliquis has stopped the migraine. It was easier before when I had AFib.
I've also been dithering about whether to ring the hospital and say 'I'm coming in for an appointment, can I have the Covid vaccine at the same time?' However, I think I will just wait and see if it happens. Fortunately the hospital is relatively close but it covers a much wider area and I wonder just how many of the vulnerable people will manage to get themselves there. We shall see.
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Physalis
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All I can tell you is that it is generally accepted that any stroke risk is independent of whether or not you still have AF,. In other words succesful ablation may not mean that you can stop anticoagulation. As Dr Gupta (York Cardiology) has said it is not the AF that is the problem but the company that it keeps.
In my case I don't think it is keeping any company. I'm not overweight, diabetic, haven't got high blood pressure. I'm not taking any other medication. I'm not frail.
I could add that I've never smoked or drunk much. However, I'm now frightened that my daughter may have oesophageal cancer. She had an operation up at Guy's last week to remove a tumour from her chest. She is waiting for a full tissue analysis. Not sure how long that will take.
I have two friends who both had cancer over five years ago and they are fine. It occurred to me today that the one who had breast cancer had radiotherapy and the other with colon cancer had chemotherapy. Would it be true that radiotherapy is used for cancers where, after surgery, there is a small area to treat and chemotherapy where the surgery has left a lot of loose edges?
Regarding the cancer, it is quite common to be given radiotherapy for breast cancer. It would depend on the grade of the cancer whether you have it or not. With colon cancer, lymph nodes are removed for testing during surgery and if any are positive, then chemo will be given to try and kill off any cancerous cells that may have spread to other parts of the body, but don’t yet show on a scan.
Thank you. I haven't thought much about cancer because we haven't had it in the family so far. I thought that it was going to be some sort of cyst but I should have known it might not be because of the speed they got her in .
Maybe not, but you are female and 84 so you score at least 2 on the CHADsVASC and those that know about these things say that if you have AF, you are vulnerable to having a stroke whether or not you are in AF....but I am not medically trained.
The trouble with these CHADSVASC scores seems to be that they assume you've got atrial fibrillation. What I want is something that stands on its own. Should everyone who is 84 and female be put on anticoagulants if they don't have atrial fibrillation?
I can understand what Sanjay Gupta is saying. It is not the atrial fibrillation that causes strokes but the other things that you've got going on. Getting rid of the AFib on its own will not lower your risk of stroke.
The trouble with strokes is that they have two opposite causes, blood clots in the brain or bleeding into the brain and you don't want to make matters worse.
No of course not but if you had AF (or you probably would not be here) and for some reason no longer do then you are still governed by the system of CHADSVASC. If you have never had AF then you do not come under CHADSVASC at all and would normally only be given anticoagulation after a thrombotic stroke.
In other words there is currently no stroke risk assessment tool for people without diagnosis of AF.
Yes, I can understand what you are saying but that's a one size fits all. It assumes that if you've had AF you will be always be at risk of a stroke. This is not the view of Sanjay Gupta as you will see if you watch his video above. He is saying that it is the comorbidities you have with the AF that put you at risk.
I could argue that no AF, no comorbidities, no risk.
Not for me or anybody else to advise you what to do then Physalis. I prefer to go on the accepted view of many of the top consultants that successful ablation does not remove stroke risk but understand your particular concerns regarding your other medical issues.
Yes, that's fine for everyone who had once had AFib and still has comorbidities. The top consultants have found that to be true in the vast majority of cases so I am not totally knocking it.
I quite expect my EP to agree with them. What will my eye surgeon say next week I wonder?
I was told by the Cardio the Eliquis precludes the formation of clots in a small round pocket in the upper chamber of the heart when you are in Afib. I have not had any Afib in over a year since my cryo-ablation but the Cardio says I have to take it for the rest of my life. $$$$$$$$$
Yes, I was going to mention that but didn't have time to look it up at the time. I think it's a small pocket which can catch clots and is sometimes removed.
in reply to
The clot formation referred to is caused by the specific conditions occurring in the heart when AF is present. If the EP considers anticoagulation still necessary when AF has been controlled you must have other risk factors present. If not anticoagulation would seem to create an unwanted bleed risk.
I have decided to keep taking it. I haven't seen hide nor hair of my EP since he did the ablation seven months ago so I've no idea what he thinks. I was told beforehand that I had to keep taking the bisoprolol but I stopped that after a couple of weeks.
I believe the risk/benefit ratio is favourable towards anticoagulation if AF is present. I don't think this is the case without AF unless the patient has other conditions or a history of TIAs.
No one on this forum can - or should - advise you on stopping an anticoagulant. It has to be done, or not, in consultation with your physicians.
The company which AF keeps as set out in CHADsVASC scoring refers to an individual's risk of stroke, whether or not they are currently in AF or AFlutter. Briefly, it stands for
Congestive heart failure
Hypertension
Age - over 65 - 74 and over 75 when the risk increases
Diabetes
Previous stroke or TIA
Vascular disease
Sex - being female (this has been disputed amongst some experts)
I am female over 75 so my risk of stroke is high even though I haven't had AF in nearly 7 years and have no other co-morbidities. You can assess your risks of stroke and bleeds with CHADs and HASBLED to help you discuss this with your doc.
When I saw the doctor at the community cardiology service it was quite simple. He showed me some columns of figures with the risks of a stroke caused by a clot or a bleed. With atrial fibrillation the risks of a blood clot in the brain was twice as high as a bleed.
However, with migraine the chance of a stroke caused by a bleed is, I think, twice as high for someone who doesn't have migraine. Would the anticoagulant increase that risk? Is the apixaban causing the bleeds into my eye? Is it stopping the migraine attacks?
Will the eye surgeon say stop the apixaban and when I go for my six month check up next month will the EP say stay on it? If I stop it will the migraine come back?
I don’t think anyone can answer those questions as there are no certainties in this life. In your position I would be thinking of the relative risks ie: I wouldn’t like it but I could live with migraines so that would be my least concern.
Stopping Apixaban temporarily if advised to by my eye surgeon would be my priority as I I’m not sure I would want to risk sight loss but I would want to know more so get up a list of questions.
I’m not sure I would want to risk stroke long term but it would be a matter of priorities.
It sounds like you feel overwhelmed, not surprising!
Breath - 1 step at a time - work out priorities. It’s very hard when you are worried about more than one issue at one time.
Yes, this is one of those situations where you try to work out a solution to a problem when you haven't got enough information and you go round in circles.
It's not losing my sight that concerns me, it's the possibility that, if I am having small bleeds into my eye, then am I having them into my brain as well.
Also, if I have a fall and hit my head, could that be worse if I am anticoagulated?
It will get sorted and I suspect I will end up not taking the apixaban. We'll see.
My consultant was more concerned about me having a stroke, than he was about my atrial fibrillation. He corrected my atrial fibrillation with a cardioversion, but very strongly insisted / recommended I continue with Apixaban.
It was almost as though if the consultant could get all the over 70s off the street and give them Apixaban, then he would, because he was seeing the damage done by strokes.
After about 18 months I (along with others) started having nosebleeds, annoying, but easily cured by reducing the anticoagulant dose, thus even mild bleeding was not a "show stopper".
I had no co-morbidities. I had only AF. I was not on an anti-coagulant. I had a stroke. I listened to the video. I guess my case exists outside the "company it keeps" premise. I'm happily on apixaban now.
I too have no underlying health conditions, am not overweight, am. 65 and still working full time. I have AF and am on the list for an ablation. I asked my EP if the ablation is a success might I be able to come off Apaxiban. He said no, you could never tell if someone might have a silent attack & he said I should be on them for life
In your position I would stay on it, I was given the option to come off it but I refused you can't undo a stroke and apixaban is the safest anticoagulant. Andy
I don’t think you need to be embarrassed about “dithering” on this very difficult decision. I am in the opposite position to you in a sense: I have been advised repeatedly to *start*’Apixaban, particularly now that I have a Chads score of 2 and have had episodes of PAF and ectopics recently. My reluctance is based on the fact that when I took dabigatran in 2018 I got an subconjunctival haemorrage shortly afterwards. Whilst this isn’t serious in itself, I took it as an indicator that I would be vulnerable to a more serious optical bleed. Your post has brought this home to me.
I don’t know the answer to your quandary. At the least I would insist on being seen by an opthalmologist immediately for a more thorough evaluation and discussion of the issue. Whilst Apixaban is supposedly the least likely of the anticoagulants to produce an eye bleed, I read recently that this may because it is a newer drug and there has been less reporting of side-effects. Some anticoagulants use a different mechanism, and so *might* be better for you (although I am not, of course, in any way qualified to make this evaluation). The Apixaban leaflet says that eye bleeds are common (up to 1 in 10) and I amazed that doctors don’t provide more information on this. I hope you manage to get this resolved satisfactorily as soon as possible.
I have a score of 2 female and 65 and one episode of AF so far. Am sticking with my aspirin I was taking 150 Mg /day long term off my own bat for years before the AF incident . If you stop taking long term aspirin apparently your cardiovascular risk goes up by a third and doesn’t return to normal so after discussion with cardiologist we decided we d stick with my aspirin and fish oil. Its a rock and a hard place dilemma and some of it boils down to what you choose for yourself
You rather surprise me. Back in 2013 my doctor wanted to put me on an aspirin a day. I told him that I didn't want to take it because I was concerned about it causing bleeding. My doctor probably wasn't pleased and it went down on my notes that I had refused.
Then two years ago I saw an article in the paper so I was glad I hadn't taken it.
Yes I ve read all that and also been around long enough to realise that medical opinion changes like the weather . I take enteric coated aspirin with lots of food ( dinner ) and haven’t had any problems. NOACs aren’t without their drawbacks and haven’t really been around a long term. Takes decades for things to emerge doctors are very poor at filling in yellow cards to report adverse events. All I can tell you is have taken omega 3 6 and 9 for decades. Ran out once and got the most awful palpitations until I re started . My body seems to get used to things and doesn’t like change . There isn’t a one size fits all solution to anything. You do your research and take your decision in partnership with your doctor
I think there is an element of fear around change for most people . And these days doctors are very protocol driven which can lead to a one size fits all approach and a reluctance to deviate. Bisoprolol being an example of that . Seems to be first line everywhere and yet the evidence of the many people with severe problems with it is not collated or recognised or reflected in patient advice. And that’s just one example
I had a CHADSVASC score of 2 for being over 65 and female. For a couple of years now the European Society of Cardiology guidelines have been changed for women to say that if the score of 2 is for sex and age ie no comorbities then anticogulation is not necessary. So my cardiologist said I need not take it. I had a TIA putting my score up to 3 and went on Apixaban immediately. As you are above 75 and female I think your score would be 3. Perhaps as someone else has suggested you should enquire about the lower dose. Because of it's short half life Apixaban needs to be taken twice a day so just taking it once is not a good idea. If you are determined to halve the dose it might be better to break the pill in half so you are still taking it twice a day.
Thanks that's very useful, I will do that. I'm still very undecided but will see what the eye surgeon says on Wednesday. And the EP next month.
If I do stop taking it and the migraine comes back I will record how often it happens. With something that comes on at random and usually lasts for only about an hour you soon forget about it. I might guess that I had three attacks a year but I really don't know.
From my experience bleeds are a problem that nothing can be done about, so no point worrying about them.
Your age means you are at risk of a blood clot type of stroke and the Apixaban will reduce that risk. Personally I would stay on the Apixaban unless a doctor tells you otherwise. I think if you read the instructions that come with the tablets at your age you should be on 2.5mg twice a day.
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