Thanks to the member Quest4NSR and his post "Great video", many of you will have to change your idea about 5 time larger stroke risk in patients with AF. Here is what prof. Schilling has said in his presentation, which can be listened to in the mentioned post:
"We used to think that AF is the cause of stroke because the blood stagnates in the atria, forms clots, and flows the way to the brain and causes stroke. Now, we understand that it is not as simple as that, because, if you get rid of AF, it doesn't seem to have any impact on the risk of stroke, so maybe that AF is another risk marker and not just the cause of stroke. So, whatever rhythm you are in, it doesn't matter, your risk of stroke is the same and it's important for the patients because every time they go into AF, they may think: "Oh, I am going to have a stroke!" and actually no, there is no more risk than when they were in normal rhythm."
I had an additional thought on the back of this excellent presentation: when previously undiagnosed AF is found in a patient hospitalised for stroke, which has come first? Stroke or AF? Within the statistics, is stroke being attributed to AF, when actually it is sometimes vice versa. The research link below supports this idea.
”Clinical observations support the hypothesis that stroke may trigger AF. Strokes affecting cerebral autonomic centers seem particularly associated with new-onset AF that lacks accompaniments of long-standing AF, such as left atrial enlargement”
I reckon my thyroid cancer caused the AF which caused the stroke. Why? Because I had symptoms of AF before the stroke. Prior to stroke no meds. The Thyroid cancer was discovered on day 4 in hospital.
It has long been known that succesful ablation to terminate AF does not remove stroke risk so I'm not convinced this is really a new thought. Whatever, I have no intention of stopping anticoagulation.
Bob, to be honest, compared to "5 times larger stroke risk", it is a new and staggering thought! I have read here about "5 times larger stroke risk" so many times and have often written until now that the principle is: "Scare them to death, and then sell them whatever you want!" Have always been accused to want to spoil people's health.
You say that it's nothing new!? Why have you not, then, told the people that "5 times larger stroke risk" is a nonsense!?
You wanted them to remain on the safe side? Is it so!? Look at the side effects of new types of anticoagulants and you will see that there are entirely new side effects, pointing in a direction of causing disturbance of Autonomous Nervous System.
I was pleased Prof Schilling did not back up the "5 times larger stroke risk" as my recollection of looking at that research done many years ago is that only one small study was involved, so not exactly a reliable stat to influence members here.
A separate but relevant issue, when I read about the relatively high level of blood clots from Covid and the jab as well of course simple age, I agree for those best not to stop ACs.
I did think it was an excellent video - but I didn’t take from what was said that those with AFib don’t have that increased stroke risk. I think that York Cardiology also had a video about this. He put it that it might not be AFib directly causing a stroke, but it being ‘the company it keeps’.
So that those of us prone to AFib are also prone to strokes, and once other risk factors are taken into account then we may be safer with anti-coagulation. The video was definitely in favour of anti-coagulation.
Though I did wonder about procedures such as left atrial appendage occlusion/removal. If that is still done, then clots forming there must still be a risk factor. It’s just not necessarily the AFib that is driving that formation of clots.
I have a strong family history of both stroke and atrial fibrillation, and am very relieved to be on an anticoagulant.
People like me don't keep any company, only meds I take is Apixaban and inhalers which dont count, with 1 episode maybe every 10 months, I feel at times that I'm putting myself at more risk by being anticoagulated but yet I keep on taking them. Interesting post.
I don’t have risk factors such as high BP, high cholesterol or blood sugar. BMI not perfect - but not huge either. I take bisoprolol for rate control plus the apixaban. I think there’s a big genetic factor for me, and I have ended up in permanent AF due to fibrosis in the atria.
Doing ok, but whatever the underlying factors that caused the AF, they also increase my stroke risk. The video is good, and makes it clear that AF increases stroke risk, while not necessarily causing it in the way they used to think. My score of 2 is based only on age and gender, female over 65.
This video definitely does not say that the risk isn’t there.
It's always been a very curious thing to me about age 65 and risk of stroke. The day before your 65th birthday, your Score was 1 and you were not on an AC but a day later your risk of having a stroke is 5 time higher when presumably nothing about your physiology or anatomy of your heart had changed in that 24 hour period, seemingly giving equal weight to the vascular disease associated with diabetes, hypertension and coronary heart disease . It doesn't seem that the burden of AF is considered...I presume because there is no way to accurately measures it, particularly for those of us with very episodic bouts of paroxsymal AF.
My understanding is that the risk is there for those with AF, regardless of burden. It’s not the actual fact of being in AF at the time. Although those facts change depending on what you are reading!
I wasn’t diagnosed with AFib until I was 67, just last year. My Apple Watch detected it, though not until I had worn it for three months. So it wasn’t as frequent at that point. However, with sisters having had strokes at 64 and 65, it was always something that I worried about. I had a retinal vein occlusion at 64 - lots of tests and nothing found. I felt like a ticking time bomb. Luckily it was very treatable, though scary at the time. I think it was likely caused by that undiagnosed AF - but was told that even if I was found to have AF, it still wouldn’t count in the scoring for anticoagulation.
As it turns out, my condition changed from monthly long episodes, to persistent last Autumn. An ablation was unsuccessful. So I need to just get on with it.
I was very glad to get those anticoagulants in the circumstances. Far from feeling that the recommendations are scare-mongering, I feel that the scaremongering is coming from those who try to put people off anticoagulants. I tend to trust the medics, and the information on the AF association website etc.
Yes your circumstances is quite layered both by your very significant family history and a moderate AF burden(monthly) . There are those who have episodes as few as once a year and are absent of family or personal history of heart disease. Yet the recommendation on AC therapy is the same. The pathologic mechanism of stroke in AF is presumed to be formation of clots in the heart (from the pumping inefficiencies of the irregular/rapid that ensue while in A fib) that are dispersed into the vascular flow to the brain. My curiosity is that for those who may have a singular annual episode have the same risk of stroke as those in persistent or chronic A fib, which clearly presents more opportunities for the underlying pathology to result.
I think that the video is about the lack of evidence about that being the exact mechanism involved? It’s always what I understood too, but apparently a successful ablation doesn’t get rid of the stroke risk - so they go by the scoring system.
That's kinda my point. If the mechanism/etiology of the stroke is not grounded in science that clots arexcausing cerebral vascular occlusion, why ACs, which come with their own risk of CNS bleeding, particularly associated with falls and trauma.... which is a real risk in those older and symptomatic with A fib. So the choices come down to possible thrombotic (clot) stroke vs hemorrhagic (bleeding) stroke from the medicine tonpreventvtge clot. I believe hemorrhagic stroke have a higher morbidity and mortality rate...but dont quote me on tgat..
Risk Factors Associated With Ischemic Stroke in Japanese Patients With Nonvalvular Atrial FibrillationJAMA 2020:
Conclusions and Relevance
Previous stroke, advanced age>75, hypertension, persistent or permanent AF, and low body mass index were independent risk factors associated with ischemic stroke in Japanese patients with NVAF.
JAMA Netw Open. 2020 Apr; 3(4): e202881.
Published online 2020 Apr 15. doi: 10.1001/jamanetworkopen.2020.2881
Yes the risk of thrombotic occlusion (ischemic stroke) is higher but chance of surviving an ischemic event is much higher than with hemorrhagic stroke due to bleedingRisk Factors Associated With Ischemic Stroke in Japanese Patients With Nonvalvular Atrial FibrillationJAMA 2020:
Conclusions and Relevance
Previous stroke, advanced age>75, hypertension, persistent or permanent AF, and low body mass index were independent risk factors associated with ischemic stroke in Japanese patients with NVAF.
JAMA Netw Open. 2020 Apr; 3(4): e202881.
Published online 2020 Apr 15. doi: 10.1001/jamanetworkopen.2020.2881
Like Bob, I thought this was understood anyhow, so nothing new. I'm on anticoagulants for life.
some only hear what they want to hear, their choice of course….
in reply to
And some repeat like parrots the questionable information. It has been repeated 1000 times "5 time larger stroke risk". Why were people scaremongering the other people, if the factor is not 5 but, say, 1,2?
As I’ve said before, I don’t care about the actual stats, only that there is a risk (revealed or caused by AF - who cares?) and I’ve been offered an expensive medication to protect me, thank you! Having a stroke is life changing, as is winning a lottery prize but people do win!
in reply to
I could have sworn that I heard the Prof say that if he scored 1 or more he would take anticoagulants and recommends others do the same, if that’s scaremongering so be it but as a highly qualified and extremely reputable Doctor, I think he wants to do the best he can to protect his patients and others from the risk of stroke. Why don’t you try and do the same…..end of conversation.
in reply to
It is not the end of conversation! You will be surprised, but I am only against the usage of the information "5 times and so on". It makes people worry and feel unnecessarily endangered. Long ago, I have seen an article (mentioned it several times in this forum) where it was stated that there IS NO DIFFERENCE in stroke risk in people without AF and people with AF. I have tried to find it later, whenever I was relating to it, but never could... The truth is as follows - all of us, elderly, are at increased risk of stroke, so maybe EVERYBODY should be taking anticoagulants, regardless of AF. Just look what I have replied to the original poster, yesterday...
I don’t think someone in his position would dare…….😉
What I thought was interesting was that the Proff said if he scored 1 or more he would take an anticoagulant. He also indicated that HASBLED is not now generally considered here in the UK which is something I have heard many medics say. There is normally a proviso that if the patient, or close family members have a history of internal bleeding then it should not be overlooked but generally, the risk of stroke far outweighs the risk bleeding. Also interesting that he said taking anticoagulants should not prevent people from pursuing outdoor pursuits which is perhaps another indication that anticoagulants do not, in themselves cause spontaneous bleeds but obviously are likely to make it more difficult to stem a bleed should one occur. I guess it’s all down to using common sense based on the information provided by them that should know about these things………
Nothing new in that idea Nesko - the phrase 'the company which AF keeps' that can cause strokes has long been well known. That is in addition to the clots which can form in the left atrial appendage during AF itself.
Anticoagulation for life for me - and nothing to do with being scared to death, just being sensibly informed.
Why is it recommended to take blood thinners even after successful ablation? If atrial fibrillation is the cause of strokes, then this makes no sense, as clots no longer form at the appropriate location when the heart beats regularly. It makes much more sense to think that most people with atrial fibrillation have an older age and are therefore also more susceptible to strokes.I am speaking here not for or against the ingestion. But you have to keep in mind that the general risk of various problems also increases as a result of taking blood thinners, from dementia to cerebral hemorrhage. The extent to which risks and benefits ultimately look in each case is likely to be very difficult to calculate. It remains exciting.
Danke vielmals fuer die likes, tomtom! Ich habe lange als Dolmetscher fuer Deutsch und Englisch gearbeitet (my second job).
We have to deal here with a lot of unknowns - medical science admits not to understand much about cardiac arrhythmias, not much about clot formation, not much about BP increase and regulation... Why is it so!? In my humble opinion, all these things come to exist as a consequence of disturbed body automatics (Autonomous Nervous System). It's all too complicated and will not be understood for a long, long time. So, to tell the truth, we are all stumbling in a dark. In one of my recent comments, I have said "I may have a stroke (not taking any medications despite being 71 yo), but those on anticoagulants (and other medications) will for sure put tons of chemicals through their kidneys. God will know what is better...
Hi Cookie, You might want to look up Dr. John Mandrola's extensive commentary on the Watchman device, somewhere on his site, drjohnm.org
He is an EP cardiologist who has AF (controlled now, I believe--he was an endurance cyclist). He analyzes all of the studies on Watchman and has some specific concerns. Best of health, Diane
And I'd just like to add that some time ago I decided to track down the origin of this '5 x increased stroke risk' which has been quoted to me multiple times and gets bandied about constantly to and amongst AF sufferers.
I eventually tracked it down. It came from a study done in the 70s as part of the huge Framingham study that began in the 40s. The study in question is the Wolf study and it studied stroke risk in AF sufferers and one of the final conclusions was the '5 x increased stroke risk'.
BUT people with PAF were excluded from the study from the get go. I'm not saying that there's no increased risk for people suffering from PAF, I'm just saying that that '5 x' figure does not apply to us.
Thanks so much for the information! Finally we know where it comes from!
In the course to calculate the exact ratio, if at all greater than 1,0, it would be necessary to know the exact data about the people with AF and the people without AF in the population, what is absolutely impossible, due to the fact that a huge number of people have AF, without knowing it at all (no symptoms, no diagnosis, ne trace of it). I hope that the ratio 5,0 will go to deserved pension after all, lol!
Ithink that you have got it about right. I also read the study and it seemed to exclude those with PAF. I guess that the actual increase in risk is somewhat less than fivefold. Perhaps future research and scientific analysis may shed more light on this subject.Regards
"We excluded subjects with stroke prior to the onset of AF. Persons found to be in AF for the first time when hospitalized for stroke were excluded, as were those with known paroxysmal fibrillation. In order to provide a clear and prospective picture of the development of stroke in AF, we included only subjects who were fibrillating on biennial examination. "
Sorry, I just wrote a reply to @Nesko with mention of The Framingham Study, but hadn't seen the link you had already supplied. Oh well, 2 is better than none.
The information about the source of the "5 times risk" has appeared on the Forum previously, but you said you have missed it. The particular Forum member who posted it is no longer a member and I suspect mostly because of the negative feedback she had to endure.
I will copy&paste her original words ...
"This study is the source of the "x5 risk for stroke in AFibbers" figure regularly quoted by all and sundry and can be found here:
Wolf PA, Dawber TR, Thomas HE, Jr, Kannel WB. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: the Framingham study. Neurology. 1978;28:973–7. [PubMed] [Google Scholar]
On first glance I could see that the study compared people with AFib and RHD (rheumatic heart disease) with people with AFib and no RHD, the conclusion being that there is a x17 risk of stroke in the former and a x5 risk in the latter.HOWEVER (drum roll....) this evening I took some time to read through the Wolf study more fully than my original quick scan....and imagine my surprise when I discovered the following:
"We excluded subjects with stroke prior to the onset of AF. Persons found to be in AF for the first time when hospitalized for stroke were excluded, as were those with known paroxysmal fibrillation. In order to provide a clear and prospective picture of the development of stroke in AF, we included only subjects who were fibrillating on biennial examination."
This means that people with paroxysmal AFib weren't even included in this particular study and that all subjects had persistent AFib!I'm staggered that this figure (of x5 risk) is applied so indiscriminately……..”
The article referenced above is easily available online, and is worth reading by all.
Thank you very much, ozziebob! I am with this forum for longer than 10 years, but sometimes I would unsubscribe, trying to walk away. But, after couple of months, I would always subscribe again, with a different name. The mentioned post must have been written where I was absent, so I missed it. Will surely find it and reed it! After what I have seen in your comment, x5 risk factor has no sense at all. Can you imagine that this number was used regularly to frighten the people. I hope that they find relief in the words of prof. Schilling, who is a renowned person in UK.
Yes you are quite right Joy. Here’s one study to that effect. It’s conclusion reads:
“There are no long-term safety and efficacy data for beta-blockers in the treatment of atrial fibrillation and there are several emerging concerns regarding their use. Considering the uncertain evidence basis, the known unfavourable side-effect profile, and the availability of alternative medications we avoid beta-blockers in patients with atrial fibrillation in the absence of a clear and specific indication. When considering the high prevalence of atrial fibrillation, there is an urgent need for larger randomized outcomes trials that compare rate-control strategies.”
Good one. Your link was from a different research. Interestingly I have my Doctor questioning BBs in AF patients.
Although I sent a copy to my STROKE DR who was tod by me that it was a NO to METOPROLOL but she still gave it to me. Like I said it made me breathless, fatigued, no emergy in exertion and the 24 Hr Heart Monitor proved that at night Metoprolol gave pauses on 47 avge H/R.
I hope our base hospital leaves BBs behind us for us AFers.
To be clear, he re-emphasised that AF sufferers WERE 5 times more likely to have a stroke and that this did not diminish during periods not in AF. Sufferers should therefore be assessed on the CHADS2 score and, if scoring 2 or above should be encouraged to take DOAC ( blood anticoagulants - or blood thinners as some people incorrectly refer to them). His point was that at a likelihood of 2% in any year, you’ve a 20% (1 in 5) chance of having a stroke in the next 10 years - too high to take the risk considering the potentially devastating consequences against the minimal risk of the meds including taking into consideration the risk and consequences of a brain bleed.
The real good news in this video however, was that caffeine was not a trigger for AF. Good bye decaf…..
Seriously though, an interesting video worth 25 mins of your time.
This is a newer comprehensive study. You can unpick the data in many different ways. However, the conclusion is that previous stroke/TIA is by far and away the main marker for subsequent stroke risk. Age being the next, the other CHADVasc factors less so. The 5x risk factor is not a one-size fits all; the risk is nuanced and graduated, with 5x being the maximum end of the scale.
Thank you Silky for the link. Very interesting. This large scale study indicates that the increase in risk of stroke for me from having Afib is 1.4 fold. This is remarkably less than the 5 fold which is often mentioned. Indeed the study clearly identifies the major risk of a future stroke is a previous stroke.Regards
I have read extensively about the stroke risk of AF , I take it all it all into account.
I also value the experience and knowledge of people like BobD who must know as much about AF (if not more) as many 'medics'.
With a CHADS score of 3 and the recent advice from 2 Electrophysiologists that I must continue to take anticoagulation following an ablation and cardioversion , I will be continuing to take my medication until the case for not doing so is proved otherwise.
Absolutely! If I were in your shoes, I too would be taking my anticoagulants without a shadow of doubt.
I’d like to set aside the anticoagulants debate for a moment and talk about the fear factor. The data in this research show that ‘5x more likely to have a stroke’ does not apply to everyone equally. It is a needlessly frightening statistic if it is not accurate. And patients don’t need to be any more frightened of AF than they already are.
I could then return to the anticoagulant debate, however, by asking how can I make an informed decision if I’m not being given an accurate risk factor in the first place?
Fear.... I am not fearful but having nursed my late husband who had a stroke when our baby was born I prefer to lessen my chances of having one if possible .
Of course stroke risk doesn't apply to everyone equally, that is why we have the CHADs scoring system and it matters not to me if I am 20x 5x or 2x more likely to have a stroke without anticoagulation, and increased risk is worth avoiding.
Nesko, THANK YOU for posting this. I have been barking for quite some time about how misleading it is to say "5 times the stroke risk"--with no consideration of an individual's total health history, or the actual leading triggers for stroke: overweight/high BMI, sedentary lifestyle, high blood pressure, age, diabetes, high cholesterol, high anxiety, previous stroke or TIA, etc. etc. A scary statistic like "5 X, etc." needlessly raises anxiety and lacks the essential question, "What is my specific, individual absolute risk vs. my relative risk ?" Anticoagulants are now proving to have many long-term side effects that no one talks about, ie., elevated liver enzymes, shortness of breath, intestinal symptoms, etc. The attitude of smug scolding when someone chooses not to take "the pill" is inappropriate; people have good reasons.
So glad that you share my views about stroke risk and the rest! Barking in duet may be herd much further, lol! Such an ratio, like 5x, can never be estimated or calculated with sufficient exactness. Why!? Because it is absolutely impossible to make an representative sample. Many people do not know that they suffer on AF and will never know. Many have had several attacks and have no idea what it was at all, some have very rare bouts, some have comorbidities which distort the situation etc. Such an ratio has the sense just as it has been used - to frighten the people and make them take pills.
I tried for long time to understand how clots come to exist in people with AF... There is the possibility that, when in AF for prolonged time, the production of platelets increases. In combination with dehydration, what may come when peeing a lot, what AF patients sometimes do, the concentration of platelets may increase above the critical level, so they may start to aggregate and form clots. But, after years and years of braking my brain, the truth seems to be very different. Such, that I would rather keep silent about it... In general, there is no difference between the people with AF and without AF, but nearly all of us, elderly, are endangered with getting clots. Despite it, I would never take anticoagulants (not advising the same to others). Agree totally with you about the side effects and possible dangers when taking them.
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