Medication review

[SteM]

I have recently had a medication review from my GP(pharmacist). As I have now turned 65 it looks like in addition to the Flecainide/Bisoprolol I also will also need anticoagulants. I was diagnosed with loan Paroxysmal AF about 20 years ago but have only had 2 episodes in the last 4 years and the most recent being 2 years ago so would appreciate any opinions on how to proceed, is it a given that this is the next stage? Very active, still working and healthy at the moment, don't smoke and gave up alcohol 3 years ago. I suppose I'm a little concerned that I may have to stop a few activities due to the risk of being on blood thinners as I ski ,cycle and work as a builder.

[BobD Volunteer]

Ive been on warfarin for 20 years and never given anything up. I still build race engines and machine things, use chain saws , axes and similar vicious machines whilst maintaining my large rural garaden and apart from one rubber glove that once filled with blood after I had hit my thumb with a hammer, never had any bleeding problems. (that stopped quite quickly once I worked out where the red spots were coming from.) Can't ski anymore though due to arthritis!

[SteM in reply to BobD]

Thanks Bob sounds like my kind of life style only I'm not one for rubber gloves.

[BobD Volunteer in reply to SteM]

Dont knock what you never tried!

[fairgo45]

Ive been on warfarin for about 10 years I have never had to stop what I've always done and never had any bleeding so listen to what Bob's saying after a while you just won't think about it

[Mcopt]

Hi its a difficult one, I am 68 my last episode of AF was over 18 months ago this was stopped by flecainide which I still take 100mg bd along with bisoprolol 1.25mg. My history of AF is only about 4 years and have had only 3 or 4 episodes until the last one they only lasted a couple of days and self converted . I was however put on apixiban and had been taking it reluctantly up until last summer. Like you I am active I ride a motorbike keep meaning to ski again but had double hip replacement and just not got the confidence back but I will. I read a study on treating anticoagulants as a pill in the pocket and have opted to go down that route for now,I keep a supply of apixiban and carefully monitor if I am going into AF using a smart watch, a kardia mobile and a wellue monitor which can be worn for extended periods and during sleep. If I go into AF I will start immediately back on apixiban, it is a difficult decision only you can make and to an extent is a balance of risks, but so is life unless you curl up and do nothing. I spoke to my cardiologist about it he was comfortable about it I try and maintain a healthy lifestyle my bp is controlled reasonably well,I may review this regime when/if I reach 70 . Another reason is that I am O neg blood group so in the event of an accident needing transfusion I can only have O neg blood which could delay things and the heavy bleeds as a result of anticoagulants could lead to bad outcomes . Sorry to ramble on but it is something I think is not given enough consideration to. Ultimately only you can make the decision for yourself the pip approach to me seems a good compromise but won't suit everyone, there are some studies out there if you Google it. All the best 👍

[SteM in reply to Mcopt]

Thanks for your reply

[bean_counter27 in reply to Mcopt]

Sounds like the REACT-AF trial which is currently underway but might be a few years before there's an outcome. Participants have paroxysmal or persistent AF and low-to-moderate stroke risk (CHA2DS2-VASc score 1-4). Some will take AC continuously, while others will only take AC when they have an AF episode lasting at least x hours (8?) and cease AC after one month (presumably unless they have another episode during that time).

Trial is attempting to get away from one size fits all approach to using AC for people with AF i.e. normally prescribed irrespective without regard to how often and how long they individuals are in AF. I'm hoping the results are positive and are out in time for when I turn 65 in a few years time i.e. I much prefer the idea of PIP for AC as only one of my episodes in past 12 months would have resulted in taking AC under REACT-AF protocols i.e. would only have been on AC for 1 month in 12.

[Mcopt in reply to bean_counter27]

I think that was the one there are also some others, the key factor nowadays is that reliable self monitoring is now possible and that really is the key to being able to treat AC as pip assuming there are no other risk factors for stroke risk. Unfortunately current protocol is a one size fits all approach and many GPs have very little understanding of AF and will just want to cover themselves, we really have to take seriously the risks of AC in certain people and lifestyles. I certat this stage would not discourage anyone from going on AC if deemed to be required by current knowledge but equally there are cases where the balance can tip against AC imo or at least a pip approach.

[secondtry]

I don't buy automatic NHS age targets. No substitute for a frank discussion with your cardiologist (not your GP unless you are very lucky) and then take the decision on your gut feel we can't really help as too individual and subjective.

[SteM in reply to secondtry]

Yes I intend to have that talk with them. Thanks

[Drone01 in reply to SteM]

I imagine you must have risk factors other than age to be recommended anticoagulation. I understand the am is to lower the risk of stroke from clots forming in the atrium whilst in AF. I found Richard Schilling’s review helpful in forming an opinion myself - youtu.be/JWS29oRlyEA?si=kmp...(Not working as expected?)

[Tplongy in reply to Drone01]

Very interesting Drone, many thanks for posting

[Omniscient1 in reply to SteM]

Yes, have the talk, it's your health. The science is universal for what it's worth, it's not an NHS thing (I think it originated in the US). At the moment (I'm 61) I am a low stroke risk, hopefully by the time I get to be 65 and the stats show I'm a moderate risk I won't be a younger outlier in the stats, and so taking anticoagulation then will do me well for getting beyond that range.

[AmandaLouise77]

I'm on thinners, asked cardiologist about cycling and skiing, she just said wear a helmet and get checked out at a&E for any bangs to the head that are hard enough to cause a bump or make you dizzy.

[Desanthony in reply to AmandaLouise77]

I used to think I'd look a bit of an idiot wearing a helmet but after a very bad crash years ago where I| was actually stationary and some one ran into me and took me out I now wear one. Thankfully at that time I wasn't hurt too badly but it was an amazing crash to watch apparently and my son wondered if he would be taking me home bandaged up or worse. this was before I developed AF.

[BobD Volunteer in reply to Desanthony]

I young lad I worked with was hit from behind whilst stationary. Wearing no helmet he fell off hitting his head on the kerbstone and was never the same afterwards. Helmets save lives.

[Ppiman]

I was told that the one episode of AF of AF I had after my ablation for atrial flutter in 2019 meant anticoagulants were for life as the chances of its return are likely (it has); also, the cause of the tiny clots or micro-thrombi that can lead to stroke are not fully known and just might not be caused by the AF alone. They apparently form is a small part of the top of the heart called the atrial appendage and I have read that the shape and size of this varies and different shapes produce widely different results regarding clotting likelihood.

In your case, being 5 years younger than I am, I guess the calculation of stroke risk (the Chads2 score) points to your need for them.

Steve

[Desanthony]

Ive been on apixaban and have not given up any of those activities you mention - though not been skiing since lockdown. At the beginning I was probably a little more careful but still don't wear gloves - even when gardening - and my wife bought me a lovely pair of long gauntlets for pruning roses and cutting trees. Hardly ever wear gloves but my wife does tell me off for this but take no notice.

[Desanthony in reply to Desanthony]

Went skiing about a month before my hip replacement in April 2010 at that time it was harder to walk than ski and went skiing again later that year I think I fell about 3 times quite badly on my new hip - once replacing a bit of trellis in the garden - I was about 2 foot off the ground but really hurt myself - hip was fine, then had a wonderful tumble skiing - thought I had stopped successfully but either I hadn't used enough force on that leg or something else happened and tumbled down yet again - only pride hurt that time and hip fine. Then tumbled off the first storey roof replacing an aerial after a storm had moved it - broke a couple of ribs and tried my best to turn myself around and avoid falling on that hip but didn't work. Hip fine yet again. I think I probably managed to hurt myself more trying to avoid landing on my new hip and each time I couldn't do it.

[OzJames]

do you know your Chad score? Mine is 1 and Cardiologist said if I go into AF then take Apixiban for a month after regardless of duration of AF. I’m 66 and he said we can review annually or when I go to a 2 in Chad score. Allowing for no other issues, that is at 74 I’m advised.

I am very active and know when I’m in AF I also have an Apple Watch and am aware of AF before the watch notification. He also mentioned that clots can start forming after 24 hours of being in AF.

My AF started 31 years ago and for the first 29 years only on average once every 4 or 5 years. I’ve had 3 episodes since 2022 and had cardioversions each time and prior to them a TOE procedure which is ultrasound of heart to see if clot is forming. Each of us have different circumstances and the risk of clots from AF or of bleeds due to anticoagulant is real and not to be taken lightly.

I’d read somewhere a trial is underway using monoclonal drugs as an alternative to anticoagulants but outcomes are most likely 5 or 10 years away.

[RepublicofFlaxpool]

Anticoagulants have risks. Remember Donald Dewar. The benefits have to outweigh the risks. This can be a fine balance. A CHADVasc score and patient preference should be taken into consideration when deciding with your Cardiologist. Age related decisions are ageist by definition! Don’t let them impose anything on you that you don’t agree with or understand. 😡

[bean_counter27 in reply to RepublicofFlaxpool]

Unfortunately the risks of AF and strokes are, to a certain extent, ageist too!

[Tomred]

Hi Stem , i never thought i would have to take any medication, but lo and behold i took af about 35 years ago but only properly diagnosed around 10 years ago , i am male coming 64 , have af approx every 7-10 days which last approx 24 -36 hours , i take multaq and bisoprolol and i wish i was 65 next birthday so that i would be offered anticoagulant, the anxiety each time i go into af is real, hopefully trials with pip approach prove fruitful, choice is yours but i like the thought of some protection, if it meant giving up skiing so be it .

[Pommerania78]

What do you think you are doing well that keeps you from having episodes? Thanks.

[BenHall1]

In contrast ..... I'm pretty unhealthy, sedentary, still booze on but less than I did, don't exercise much, watch my food intake (quantity and type ) was diagnosed with paroxysmal AF at 65 ( Jan 2010 ) - elected for drugs for life ( no ablation or cardioversion ) was put on Warfarin at the get go, beta blockers too, still keep my PCV licence - pass annual medical and have a part time job driving college students to and from college ( teenage and adult ) ......... plenty of mental challenges when driving ( particularly in tourist season where I am ) . Have no plans on stopping yet a while unless I fail my annual DVLA Medical. All medical conditions declared to DVLA as are medications.

[Sixtychick]

I had an ablation in September. . They are stopping my heart tablets, but I have to be on anticoagulants for life. I have a CHA2DS2VASc score of 2. Anything over 1, I believe, is advised to take anticoagulants, if you’ve got AFib. You can get this score tool on the internet, if you type in the above. I was worried about taking these , but I believe that the main worry, is if you hurt your head in an accident ,as it is classed as an emergency. I’ve had teeth out without stopping the anticoagulants, (Dentist said no need to) and I really didn’t have a lot of bleeding afterwards. I’d rather take anticoagulants, than have a stroke. A lot of my relatives have died from strokes or heart attacks.

Best thing is to get advice from the Doctor, over whether you should give up the any of the things you enjoy doing.

[Buzby62 in reply to Sixtychick]

From the AFA info sheets, click on the screenshot to open up.

CHA2DS2-VASc

[MWIC]

Apixaban and no probs so far and haven’t stopped anything including my apparent love of knocking myself clean out running into Invisible plate glass windows whilst under the influence

[Skertchly]

just go with flow. You’re doing all the right things. A pint of beer a day won’t harm you.

[SteM]

I would like to thank everyone for taking the time to reply to my post, some great info which has been very interesting . Next step for me is to get an appointment with my GP so we can discuss the subject,. tried to get in today but was blocked by the ever guarding receptionist who told me to do an online request. Probably will end up paying for a private appointment with a cardiologist again. I will post whatever the results are in the future.

[Vonnegut]

I cannot see why you need to be on anticoagulants if your AF is controlled by the drugs you are on! Sounds like box ticking to me with no common sense involved! If you are not experiencing lengthy periods of AF with a very fast heart rate you are not at risk of stroke according to the lovely EP I saw privately, after the lowest dose of Bisoprolol proved too much for me to take daily. He prescribed Flecainide for me to take as a PIP but as episodes increased I now take it regularly and haven’t had an episode for well over a year now. We know we are all different and I hope you can find what is really appropriate for you.

[RepublicofFlaxpool in reply to Vonnegut]

Exactly. There is a lot of Guideline following these days and they are just “guidelines” not protocols!

Always read the label!

[Buffafly]

Hi, the PIP anticoagulant idea is very tempting but I couldn’t use it, reason being that I had a monitor for a week and discovered I had had frequent episodes of AF I wasn’t aware of. So it’s not something I would try without having had a monitor for some time.

[Vonnegut in reply to Buffafly]

It isn’t a PIP anticoagulant idea!!

[bean_counter27]

It is certainly a subject to discuss with your doctor. There are arguments for and against taking AC from your perspective. One of the issues though will be whether you might be having more episodes than you think you're having and also knowing their duration. If you have some sort of device monitoring for AF then that shouldn't be an issue. However, if you don't then it is possible you might be having more episodes than you think, with some of them being asymptomatic or possibly occurring while you are sleeping.

I commented on the REACT-AF trial in an earlier comment on this post. The trial relies on participants wearing an Apple Watch daily to help detect episodes of AF, which largely overcomes the issue of asymptomatic episodes being missed.

I'm not on AC (only 62) but watching the REACT-AF trial with interest. My gut feel is it makes more sense than the current "one size fits all" approach but I'll have to wait and see whether the trial's PIP approach produces better outcomes.

[SteM in reply to bean_counter27]

What is considered to be the best watch for detecting AF?

[bean_counter27 in reply to SteM]

The Apple Watch is often highly rated but you probably also need to have an iPhone for it to connect to. I don't have one so better to ask others about the pros and cons about using it for AF detection. One issue I do know of is battery life. My wife has to charge both her Apple watch and iPhone daily.

The Apple watch is being used for the REACT-AF trial but I believe they are using a modified algorithm for AF detection i.e. differs from that used on Apple watch available to the public. I suspect it checks more frequently and/or has lower threshold for alerting user of potential AF event but I'm only speculating. Again, suggest you check with others who currently use it for AF detection. If it hasn't been a post, it would be a good one to ask users on the forum how they use their wearable devices to detect and alert them to AF episodes - and how good a job it does.