Continuation of stroke risk after ablation.

[BobD]

I really don't know how I can explain this any more but I will try.

If your CHADS2VASC2 score is zero and you are put on anticoagulation purely for the purpose of the ablation and post procedure recovery then anticoagulation may be discontinued once the three to six month recovery is completed, especially if a 72 hour holter monitor showed no AF.

If on the other hand you have other co morbidities such as high blood pressure, diabetes or pre existing heart disease then your risk continues regardless of how successful the ablation may have been. Whilst this may not suit your wishes, it is fact. Dr Sanjay Gupta did a video on this some years ago and stated "it is not the AF which causes the risk but the company it keeps". The combination of factors which make up the CHADS2VASC2 score alone can creat this risk.

There are other factors at work here as well. The process of ablation causes changes to the inner surface of the atrium which can disturb the natural flow of the blood. Forget the Left Atrial Appendage here,. we are talking about roughness on the atrium wall which can act like fer in the pipe work of your central heating system and disrupt the smooth flow. Any eddies can therefor allow a clot to form. You must also understand that whilst you think you may not have any AF you may be asymptomatic or having events whilst sleeping.

When I last saw my EP who did an angiogram and fitted a pacemaker in September he told me I was in AF when he was working on me briefly despite the fact that I have pulsatile tinnitus and can clearly hear a steady rhythm around 80 bpm. As far as I am concerned I have had no AF since my third ablation in 2008 but apparently that may not be true. Had I stopped anticoagulation back then who knows what might have happened.

As the old saying goes, you can always stop anticoagulation but you can't undo a stroke. ( just checked my INR at 2 this morning).

[Pippybird]

Happy holidays. 🎄🎈

[Wallydb]

I totally agree Bob. My mother-in-law was taken off warfarin some years ago because it didn't suit her (always having blood transfusions after having bleeds) and was given nothing in its place. Some six years later she had a stroke and is now in a nursing home not able to do anything for herself whereas she was living independently before. So now at the age of 98 she is on 2.5 mg of apixaban. After the horse has bolted as the saying goes.

[sassy59]

Having seen my mother suffer the effects of a stroke at 77 and sadly passing away a week later, I’ll be sticking with my anticoagulant.

Merry Christmas x

[meadfoot]

Thank you Bob. Have a lovely Christmas. All the best for 2023. 🤶🏼

[mrsg46]

Thanks for the reminder, Bob, you've your best over the years to encourage people to think twice about stopping or taking anti-coagulants. I took your advice at the beginning of my AF journey and it's not been a problem. Taking meds twice a day is nothing compared to the possibility of a stroke and the ramifications of that (makes me shiver just to think about it).

Interesting you mention the pulsatile tinnitus which makes you feel you're in normal rhythm when you could be in AF. I have the same and it does feel like a steady regular beat if I concentrate on it, but my Kardia tells me I'm almost constantly in AF 😟

[Aprilbday]

That was a well-informed read. The ablation wear and tear information on the heart was helpful. Thank you so much. I no longer have A-Fib-no events for years now, but am almost 70, a fatty with high blood pressure. And before anyone jumps in about alternatives, I’ll just say that supplements and natural things are wonderful BUT I’ll remain on my prescribed anticoagulant for sure.

[Jalia]

Thanks Bob. I hope all those who are resisting anticoagulation get to read this.

[Walras]

Thank you. Always helpful.

[Coco51]

Food for thought and very helpful.

[secondtry]

Thanks Bob for your extra time explaining this and your valued opinions as always.

My initial reactions to your points pertaining, I emphasise, just to me, but hopefully of some use to others, are:

Phew, I don't have any other comorbidities.

Phew, I haven't had an ablation yet as don't like the sound of a possible rough atrium wall.

Events whilst sleeping do concern me:

but as I am a light sleeper, very symptomatic when in AF and wake up most nights x2 for the bathroom & over 8+ yrs have not had any night AF indications (whereas in the early days I definitely did), I don't think at present I will invest in an Apple Watch or the like to monitor this.

Being in AF despite a regular pulsatile rhythm does concern me more though:

albeit your EP did say 'briefly'. My cardiologist has given me a PIP scrip -not used yet- to start ACs if in AF for more than a few hours. I therefore intend to discuss this with my Cardiologist early in 2023. I also intend to do some more homework on pulses as I have heard mentioned we have several pulses???...can anybody help, have I missed anything on this subject?

Decision time:

I am CHADS score 1, not sure what my bleed risk (HASBLED?) score is. I will continue to postpone ACs until personal circumstances change or my cardiologist changes his advice from neutral to a more definite pro ACs.

Reasoning:

The AC debate here over years has suggested strongly all should be on ACs for life once AF has been experienced; in fact one of my posts was censored by Admin for suggesting an 'it depends' approach. I am afraid I still don't accept ACs apply to everybody. In the right favourable circumstances, in a minority (and out of 26,000 here I can't be the only one).

I believe there is a lot to gain in terms of decreased bleed risk and other perhaps unknown side effects of the relative new DOACs in timing the start of ACs more carefully based on individual assessment with of course supportive medical advice.

[BobD Volunteer in reply to secondtry]

I must correct you regarding HASBLED. This is not a bleed risk score assessment it is a list of things which need to be considered or addressed before prescribing anticoagulants. This is a common missconception but I was put right by one of the team responsible for setting it up. Bottom iine it is your choice but see the last line of my post.

[Hidden]

I signed up to a university study on the potential beneficial effects of anticoagulants in the prevention of dementia in people with AF. I was one of those selected to take the medication earlier than I would otherwise have done. So I’m happy to have a level of protection against stroke and also support the study. I just have to complete some tests every six months for the next several years ( while I can!) and leave my brain to science when I no longer need it.

[Hidden in reply to Hidden]

The thinking behind this is apparently that strokes are horribly obvious, however there is a possibility that even without a stroke there could be a low level of damage being caused by micro-clots which might over time be responsible for dementia.

It might be that earlier medication with ACs could reduce this risk as well as that of stroke. To get involved in this study and be taking an AC was a “no brainer” - however had I been selected not to take the medication then I would have probably requested medication. I’ve seen too much vascular dementia and stroke damage not to take this very seriously.

[BobD Volunteer in reply to Hidden]

I totally agree. There has been some research into the benefits of anticoagulants as a prophylactic against vascular dementia in AF patients already but the more the merrier. For example when I had my first ablation in 2005 warfarin was stopped five days prior to the procedure. By 2008 it was being continued as it was thought that the process of RF ablation could perhaps create micro embolii which maybe explained the "brain fog" some of us experienced post procedure.

[wilsond]

Well said Bob

[Goosebumps]

many thanks for the explanation Bob, sorry if the request was repetitious.

What your reply clarifies for me is your explanation that the stroke risk is still there after a catheter ablation but it certainly isn’t the 5x normal risk of non anti coagulated AF sufferers.

This also clarifies why Mini maze successfully ablated patients with the left atrial appendage occluded may cease their anti coagulation as it is the outside of the heart that is ablated.

From a personal standpoint I am symptomatic persistent and can’t be sure if some of my symptoms are related to my Apixaban because I’ve not been in NSR long enough to test. I’m backed up against a hard wall.