What are the criteria in diagnosis of atrial fibrillation disorder prior to introducing anticoagulation medication?
Diagnosing atrial fibrillation disorder - Atrial Fibrillati...
Diagnosing atrial fibrillation disorder
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JK5AEO
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BobDVolunteer
A diagnosis of AF alone does not mandate anticoagulation This is decided by your CHADs2Vasc2 score which you can google and work out your own.
Thank you for your reply. I was curious because I've never been diagnosed with atrial fibrillation disorder, have not even had an ambulatory ECG, yet I am being put under immense pressure to accept anticoagulation medicine. I consider anticoagulants to be high risk drugs, yet they are now as ubiquitous as antidepressants. I'm in favour of preventative medicine as an ethos, but I am opposed to box-ticking protocols and back-covering by GPs.
Of course, the primary care sector no longer has the resources to treat patients individually - doctors have to categorise patients into disorder groups and get them out of the surgery as quickly as possible. I am inclined to reject anticoagulation intervention except in an emergency. Of course that means that there will be an entry in my medical notes stating "patient declines treatment ", the implication being that I am a trouble maker.
Hi, yes, there is a knee-jerk reaction to the idea of anti-coagulation. I had it myself. I'd try to unpack it. First, you say you don't have an AF diagnosis. So firstly I'd ask why is this being considered? Do you have AF or something else? If you are suffering from something else then you need to consider that. Assuming you do have AF, then have the medics confirm it to you. There are variants and some cause trauma and anguish and come and go, and some hang around forever and are asymptomatic (like mine). ACs aside you may need to get on the therapy path for whatever else is available
Then as for the anti-coagulation. There is a universal, holistic scoring system which has been mentioned here which takes into account your general health to signpost to the Dr whether you are at risk of a stroke. (Then hence ACs).
I also was anti anti-coagulation but the science and prescribing has changed in recent years, and when I 'qualify' I will accept them having looked at them in more detail. A daily pill or a increased risk of stroke, not a debate for me.
There are plenty people on this forum who can go into the positives and negatives of ACs especially when taking other drugs, home remedies, different lifestyles etc etc.
Lastly, I'm guessing from your ID you are in the UK,you'll know that you cannot be compelled to undergo any medical treatment here, unlike the US for instance.
Best wishes, Gary
Atrial fibrillation is a condition not a disorder but that aside, why , if you don't have it, are you being asked to take anticoagulation? Have you suffered some form of palpitational event which was diagnosed by your doctor? Whilst an ECG is a sure fire way of diagnosing it can easily be felt with a simple pulse check. Many people sadly go undiaganosed because their AF is paroxysmal and never present when they are in front of a doctor and suffer stroke before they have the chance for treatment.
AF make us five times more at risk of stroke and to be honest the UK is one of the worst countries for protecting against stroke with anticoagulants and as a result has a poor reputation in terms of avoidable strokes. Part of this is the reluctance from GPs to prescribe the drugs. Most GPs seem more afraid of bleeds than thrombotic strokes so sorry I can't agree with your tick box statement.
Interesting opinion, thank you. The strange thing is I have an A&E discharge report, following treatment for an episode of fast AF; it says "Atrial fibrilation DISORDER suspected", so this must be referring to another type of illness. There was never a follow up because my notes were lost between A&E and Cardiology at Watford General Hospital and my GP was unable to get me an appointment. Now a different hospital has contacted me two years later insisting that I take anticoagulants. It all seems a little random to me. I'd prefer some tests before taking a high risk medication.
Sounds par for the course where the NHS is concerned. 🫤
My local hospital cardiology department said they couldn’t see the A&E notes/ECGs from my multiple visits - as it’s a “different system” apparently. And it’s 2023!! 🤷♀️
Yes, I encountered this when I attended a hospital in the neighbouring county - they could not access my medical notes. Fortunately, I keep copies of everything myself, though I am increasingly finding that I'm "not allowed" to do so.
Oh really! Don’t they trust you? 😀
I’m aware that one NHS Trust does not link patient info with another Trust. If you’re away on holiday and get sick, the hospital you go to won’t know anything about you. Hence you carrying your own ‘story’ eh?!?
In Derriford I’ve repeatedly had to tell different departments to remove the landline number they’ve got for me as it’s been redundant for years - A&E, Neurology, Cardiology and just lately Physio. I asked the physio admin why they still had the landline number and she said that “every department has their own patient records”! And more importantly they CANNOT access other departments records. Hence Neuro knowing nothing about my (avg) twice weekly episodes of protracted AFIB, nor knowing about several visits to A&E about it. And that was prior to going in for a long, complex spine surgery! Good job I just happened to flag it up so that the anaesthetist could go look at my cardiology records. 😟
(Fortunately I got through the surgery AFIB-free!)
We need to have our story with us and be captains of our own ship!!
Well, just exploiting the analogy to the full, I'd at least like to be on the bridge when the Officer of the Watch sets the ship's course!I think the problem with patients accessing notes is that there is a risk of them asking questions. As my profession is to ask questions I tend to have a natural curiosity, especially about my own health. I have found that generally there is a slightly hostile approach when the customer questions the salesman's knowledge of the product, but I suppose that is true in all industries; it's simply professional pride, which is not necessarily a bad thing.
I'm not trying to cause trouble or appear ungrateful, but I do feel that a box ticked on the strength of a telephone call could be considered risky.
True! My first ‘phone consultation’ with an Arrythmia nurse didn’t go well. After taking my height and weight and speaking to a cardiologist, she prescribed Digoxin and Flecainide over the phone and said “you can call us anytime in the next 12 months if you have any concerns”. Well funnily enough I did!! I told her I live alone, so there’s no one to see me hit the floor if I have an adverse reaction. She simply said, “I’m sure you’ll be ok.” 😡 When I started asking too many questions she got narky and shut the call down.
That’s when I paid to see a cardiologist privately to simply get more info about the AFIB and the meds. He looked me up and down (I’m petite) and promptly reduced the digoxin dose and said DO NOT take the Flec and booked me in for a heart CT scan, saying, “They should have done that as a matter of standard procedure before prescribing Flec, as it may not be the right drug for you.” It’s all really worrying - and just when you should be trying to reduce stress!!
Exactly! Stress is the trigger factor in many cases of AF, so I try to avoid it. I very much admire your assertiveness.
I have a telephone appointment with Cardiology on the 4th of July; I'm afraid I will probably ask questions.
Do! Ask away. You’re entitled to full information.
When prepping for spine surgery I came across an American website that described a study carried out where they identified two distinct types of patients. One they named Monitors where the patients needed ALL the information to feel confident and the other was Blunters - the types for whom less information makes them feel more confident. At least it answered my question as to why I always need to know the ins and outs of everything and that I’m not a hypochondriac! 😀 Information doesn’t make me more worried, in fact I feel more worried if I suspect someone is withholding information. Sadly the NHS likes to treat us ALL as Blunters.
Sorry BobD, but I can't pass this by. Paroxysmal AFib does not apply to the x5 risk figure that is frequently quoted. The x5 risk figure came from a part of the huge Framingham study that has contributed to much of the statistics used for heart conditions, and it excluded people with PAF. This figure is used far too freely, in my opinion.
Wow, you took the words right out of my mouth! I have had so far a successful ablation, excellent CHAD2Vasc2 score, as well as eating right and exercising. And still yet although my doctor stated I am fine without them, the NP continues to try her best to push them on me. Errr... the "side effects" from these anti-coagulations like most of the pharmaceutical world, no one seems to want to talk about, or brushes off like your being ridiculous and as you stated a trouble maker. So those who heed their intuition have to do a deep research on their own.
Many thanks for all responses.
Good question - link to NICE information on diagnosis and treatment nice.org.uk/guidance/ng196/...
Hi JK5AEO,
I’ve just been reading your post with interest….how strange with what has been happening to you. I am not on anticoagulant due to my CHADS score and have had Afib on and off for 18 years, 15 of those undiagnosed.
As Bob says it’s not a disorder, it is a condition, so that is odd in itself that a medic has written that. Often in A&E they are generalist doctors who see you, so I wonder if this might have something to do with it? It’s odd too that they wrote ‘suspected’ too rather than it being fully diagnosed. Why didn’t they do an ECG? Afib should be easily defined from an ECG to a person who is medically trained in analysing ECGs. How can they suspect Afib without an ECG?
I think I’d want a proper diagnosis of Afib before I was offered anticoagulation and I’d only take it if my risk score suggested I needed it.
Do you get palpitations? Is it worth getting your own monitor ( ie a Kardia) if you experience these again?
Thank you Teresa for your helpful reply.
I have had two episodes of AF, 7 years apart - one was due to an upper respiritory tract infection, and the second possibly due to Covid-19. I assume the A&E doctor's report was based on how I presented at the time, and my medical history - I was not in sinus rythmn, and had a fast HR, so they gave me a dose of bisoprolol and a few hours later I was back to normal.
I was sent home with a prescription for rivaroxaban which I took for a couple of years until I could no longer tolerate the side-effects, (I have IBS-d).
The GP felt that the sky had fallen in when I informed him of my decision to cease the medication, and that's obviously triggered a reaction within the system - I was instructed in a telephone call from a hospital nurse that although I am at low risk of stroke, have never actually been diagnosed with this condition, and have never had any test results to show anything abnormal, (I've had an echocardiogram, numerous ECGs in hospital, and recently a chest x-ray), I MUST start taking apixaban.
Unfortunately all the NOAC class drugs are gastro-toxic, and intestinal and rectal bleeds are particularly unhelpful in IBS patients. The argument seems to be that although IBS is the most debilitating condition I have, and it prevents me from leading a normal life and leads to much short-notice sick leave from work, if I don't take anticoagulants I'm going to have a stroke and die.
I'm afraid that I'm yet to be convinced by this argument, but patients who are congnisant of their condition and who ask questions seem to be considered troublesome and unwelcome.
I had hoped that the other meds I'm prescribed (ramipril, bisoprolol, and atorvastatin) might reduce my risk without having to take such a high risk drug on top of those.
I have been promised a telephone call with a cardiologist in July, and my pharmacist has advised me to state my case in the hope that he might be more open minded, though I fear he will be as risk-averse as everyone else.
Hi JK5AEO,
Thankyou for your reply, it has explained a lot, though it still doesn’t quite explain why you think it’s Afib, if it hasn’t been diagnosed, or they think it’s afib. There are lots of different arrhythmias and palpitations. It’s quite common to never have your palpitations ‘caught’ on an ECG at hospital, if your episodes happen so infrequently, as was the reason I was never diagnosed for many years as mine were so infrequent. It’s all still a bit odd! I would have thought that they should have put you on an ECG monitor the last time when you were having the palpitations and seen if it was actually Afib…for them to say it was suspected or whatever, doesn’t make sense. There isn’t anything else called an Afib disorder, Afib, is Afib and it most definitely is a ‘condition’ 😊
Again, as previous comments have said, your risk score would determine if and when you need anticoagulation and it sounds like you are low risk, so the chances are it may be 0 or 1 ( if female). I’ve been told I don’t need to consider them until I’m 65, so I’ve got another 7 and a half years yet. I do still think it might be worth getting a Kardia monitor or something similar, so if and when you get another episode you can catch it, there and then? In the meantime, if your risk score is 0 or 1 it is entirely up to you if you wish to take anticoagulants.
I have an Emay monitor which only ever records 'bradycardia' - due to the effects of bisoprolol my resting HR is sometimes below 50bpm.
As your episodes appear to be very infrequent, I think all you can ever do is wait for that feeling you get that has taken you to hospital in the past and retry and capture it on your monitor. The chances are you’re not capturing anything at the moment if it’s just bradycardia. How much Bisoprolol are you on? Are you taking it daily? When you say it’s below 50 resting, do you mean when you are asleep, or sitting in front of TV etc?
What do you think your CHADS vasc score is based on your age and risks?
I'm prescribed 1.25mg of bisoprolol daily. It has slowed my heart rate even though it is a very small dose. My pulse is usually resting around 55bpm when I am inactive.
Hi JKA5AEO,
I’m on the same - and my inactive heart rate is about the same too. It’s a misleadingly powerful pill, even at this low dose. My HR is roughly 10 beats lower than it used to be.
It’s when you don’t feel right with a low HR is when there’s a problem.
Why were you prescribed this daily, if you were never diagnosed with Afib and have only had two episodes seven years apart?
Do you know your CHAD vasc score?
I got my diagnosis when I went to A&E and they put me on an ECG and captured my Afib while it was happening and diagnosed it there and then. I was then sent to a cardiologist, ( had to wait) where I had a scan and advised what my heart structure was like and it went from there. None of this has happened to you, so I would be asking a lot more questions to the Cardiologist, when you talk to them in July,
I think it's all because I had a heart attack about 8 years ago which was induced by long term use of a cardiotoxic medication. The heart attack was a very positive event for my general health because lots of medicines were suddenly excluded. I lost 30 Kg in weight and no longer slept for 14 hours a day. Even though the two AFs have been medically explained I'm told that protocols have to be observed so that my doctor is not deemed negligent, which made me feel it was more about his reputation than my health! I would be happier if I had had test results showing some form of illness requiring treatment, but the prescription seems to be based on anecdotal evidence and assumptions.
Hi JK5AEO,
I think the fact that you’ve had a heart attack in the past, changes things somewhat. I also think it might alter your risk score, now you’ve said that. I think you need to discuss this further with an expert.
I do wish you all the best, but I’m not sure you’ll get the answers you’re looking for with your question on here.
Hi
AF, AGE over 65, gender add 1 for a woman.
1 they don't give anticoagulant.
Depends how regular is the AF persistent, rapid, episodes???
The above makes up the risk of having a stroke or heart attack.
I think what should be added is hypo/hyper thyroid, thyrod cancer which can cause AF and a stroke. It did to me!
cheri JOY 74. (NZ)
Since studies show AF is very often only diagnosed after a stroke, especially the symptomless variant, my personal feeling, is, if in doubt, take the anti-coagulant. My PAF was diagnosed by chance, not unexpected as it is familial. I was so grateful to receive the diagnosis even though it does mean daily medication and an annual visit to the Cardiologist for echos and dopplers, an appointment about which I have mixed feelings, my reaction being , 'what if they find something horribly wrong with my heart' - ever the pessimist ! You do not say how old you are, but I understand from my sister , that 65 (I'm not sure if that is just for females) is the age that it is recommended the drug be started in the UK. I live in South Africa was and was well over that age when diagnosed, I was prescribed an anti coagulant once it was confirmed that the incident picked up on the ECG was not just an isolated event.
Thank you. Can you tell me how your diagnosis was arrived at?
Yes certainly. I was working in my garden and cut my shin on a very prickly aloe leaf, despite my first aid, I noticed after a couple of days that it was showing signs of infection so I made an appointment with one of the GPs at my surgery to examine it and decide if I needed an anti-biotic. On examination it was evident that cellulitis was beginning, so she prescribed a very strong anti - biotic, to start as soon as I got home, which I did according to instructions regarding food. Unfortunately, shortly afterwards I began to vomit and vomit until I was vomiting flecks of blood. On seeing this I phoned the surgery and was told to attend immediately. This I did, was given an anti-nausea injection and usual checks during which it discovered my pulse was racing at 140 BPM. I was then hooked up for an ECG which showed AF. Since she was concerned about the blood (it was very little) and a possible dissection , the GP phoned a Cardiologist who asked that I be sent to him at once. I was not allowed to drive, so had to find two drivers one for my car and one to take ma (another story and irrelevant). Anyhow, I arrived at the hospital where the Cardio has his practice and was admitted to the cardio ward immediately. He came up to see me, and by then I was in NSR. He kept me over the weekend (this had happened on a Friday afternoon) until he was satisfied my heart had settled, and prescribed Biso, with the instruction to check my pulse regularly. and should it go over 100 BPM to go to my GP for another ECG and for her to phone him with the result. This I did. The result of the ECG was AF, the GP phoned him, he told her to prescribe Warfarin and for me to see him in a week. I saw him and he announced that I was in AF and would I like a Cardioversion - I said I might as well since I was there. He did the procedure that afternoon and my son collected me a couple of hours later (he had taken me to the appointment just in case) . This was 5 years ago, I changed from Warfarin to Xarelto, and am now on Eliquis as this site has recommended it as the better drug for AF. So in a nutshell I was diagnosed due to an infected cut and an anti-biotic that did not suit me. Sorry for the essay , but you did ask !!!!!!!!
That's an amazingly interesting story, I trust you have given press interviews?!
The thing that bothers me in my case is that any tests I have had since my heart attack show no damage to my heart, no abnormalities, and only two instances of AF. I would dearly love a more holistic approach to my health which would consider the effects of my IBS, but the focus is solely on those two AF events.
I am in favour of preventitive medecine, but not the use of medication over investigation, though I understand the obvious resourcing challenges facing the NHS - pills are much cheaper than consultants and tests.
Alas, since I was fully clad at the time, the media is not interested in my story !!!!! Here in SA, the public health system cannot cope with the volume of patients, so those of us who are able, belong to Medical Aid Societies - they are non-profit making and different from medical insurance. Because the public system employs very few doctors, all the rest including radiologists, pathologists , every specialty and GPs are in private practice, without any support from the government, thus it is in their interest to refer as many to 'friends' for tests etc,- you scratch my back, I'll scratch yours ,kind of thing, so referral for a procedure to another discipline is very much in favour. Very often specialists work in concert with each other for example a neurologist and an orthopod, or in a case such as yours a gastroenterologist and a cardiologist. We also have a number of specialist physicians, who do view the patient holistically. This system works well for those who can afford it, so I suppose in essence, today, SA is a pariah state due to a rich and poor divide, as most of the rich now, are those who would have previously been described as disadvantaged.
Sounds very much like the United States.
Maybe, but the fees are a fraction of the cost, someone was telling me that while on holiday from the UK in Cape Town she met a man at the hotel after some of them had been playing golf. In walked a gentleman with a patch over his eye, he was asked jokingly if he had been hit by a ball. He replied he had just had a cataract operation. Apparently, his GP in the UK organised it for him- the operation, plus air fare and a month's holiday in SA cost less than a private cataract operation in the UK !!!!
Wow! I'm moving now!
From your bio and your responses to replies to your post, I would guess that you may be quite familiar with the workings of the heart, so please excuse me if you are aware of most of my comments.
Firstly, the CHADS2VASc score only applies to people with AF.
I'm a relatively fit 77 year old male and have permanent but symptom-free AF. My score is +2 purely due to age, so I take Edoxaban (anticoagulant) to reduce stroke risk and Bisoprolol to keep my heart rate below 100 resting (it's typically around 85. I have never had any other heart issues or strokes.
You are a male in your mid-fifties but have had an MI, so your score might be +1, which is much lower risk that for me, but flags to the doctor that anticoagulation should be considered. However, this only applies to people with AF, so the question really is, "Do you have AF?"
You say that you had two short periods of AF several years apart triggered by infections, yet the only record of this is a hospital discharge report saying "Suspected AF". This suggests that either an ECG wasn't carried out or you had by then returned to sinus rhythm.
You have an Emay monitor (I use the similar Wellue standalone device), so you probably know that AF is primarily diagnosed when the heart rhythm is "irregularly irregular" (in other words there is no discernible pattern to the irregularity) and there are no "p waves" (a small peak just before the start of the main QRS complex). These p waves can be hard to spot on a home ECG due to signal noise but, if you are in sinus rhythm they are there whether or not you can see them. In addition, AF often causes a high heart rate - hence the use of a beta blocker such as Bisoprolol. The fast heart rate and irregularity can be determined by manually taking your own pulse, so was this how you determined that you had suffered AF during the two instances you mention?
When you are in AF the atria vibrate very rapidly (not usually obvious on a home ECG as any signal gets buried in noise) and a stagnant pool of blood may form that can clot. This clot may eventually move into the left ventricle and be pumped into the brain and produce a stroke. As you might imagine, this is a gradual process and is a very significant risk for someone like me, in permanent AF. However, with your two infection-triggered short episodes of possible AF some years ago it would appear that your risk would be much lower than mine.
As to the other drugs that you are taking (ramipril, bisoprolol, and atorvastatin), they are not anticoagulants and I can't see how they would help to prevent a clot forming.
I hope that some of the above may help you and, in conclusion I would stress that, if you ever suspect that you may again have AF, you should certainly discuss anticoagulation with your GP.
Best wishes,
Paul
Thank you for taking the time to write, Paul. The question is, how do you define an AF patient? Would I be included in this category because I have had two brief episodes of AF. That might be a little bit like saying someone experiencing a short-lived spike in blood glucose has diabetes, but they would probably not be prescribed insulin. If I was permanently, or even regularly (once a year, month, week...?) in AF then I might accept that I have a condition that requires a high risk medication. However, I have been in sinus rhythm for 57 years except on two days, seven years apart.
I suspect it comes down to resources - pills are cheaper and easier than tests, monitoring, and doctors.
I wish I could find the answer.
Best wishes.
Ultimately it's your choice. I have permanent AF, asymptomatic, and was on meds for a year or so but then was advised by a dr who was interested in af that for the moment (Chads=0) there was no point, so I'm meds free at the moment.The absence of the p-wave as someone said is the smoking gun in this and it's cheap for your GP to get an ECG done (the nurse will do it probably, not the Dr). But if you are in nsr there's no point. When I was diagnosed I asked for one annually for my own peace of mind, but don't any longer get as my heart never changed.
Then the question is are AF events traumatic for you, and will they increase as you age.
In your shoes I'd pay for a private consultation and get some quality time with a Dr. This is reasonably cheap, and would be carried out probably within a couple of weeks of you requesting it.
On records and the NHS, you have a right to see them. Drs will delay release to make sure that they haven't missed anything (you can judge why they do this yourself) but they cannot refuse to disclose them.
Best of luck, Gary
Thank you Gary. I had symptoms of AF or any test results from ECGs that showed I have AF I would take a different view, but to be in this position without any evidence that I have anything other than two rare events makes me question the assessment that I MUST have anticoagulation. In my case the risk of gastic bleeds is too high. Thank you for the information.
Hi jk, I don’t know why they stated disorder.? It’s a condition. Something must have been picked up somewhere at some time for them to suggest anti coagulants.? As far as I’m aware they don’t suggest you go on them if it’s not necessary.! a stroke from AF can be life changing.!
Take care,best wishes
Ron.👍
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