I am quite confused these days because the last time I saw a GP they decided I should take an anti coagulant where the cardio consultant I saw originally said the risk of brain bleeds was greater than the stroke risk provided that the episodes of af were of short duration. So I started taking this drug edoxaban because I tend to do what doctors say but I didn’t like the side effects. Is there a way to see how ‘sticky’ one’s blood is to assess the likelihood of clotting if one’s bp and af are all well controlled by other drugs? Any thoughts on this ? Thanks 😀
stroke risk assessment: I am quite... - Atrial Fibrillati...
stroke risk assessment
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Saladmuncher
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Hi Salad Muncher,
Your GP is correct. It is recommended that all women who have AF should be on an anticoagulant, once you’re over 65. Before that, you are risk scored based on your previous medical history and comorbidities that you have alongside AF. It may have been that you were under 65 perhaps when you last saw your cardiologist?
There are other anticoagulants apart from edoxoban that you can try, so may be worth asking your GP for an alternative?
The anticoagulants make blood clot slower than normal.
Yes you are right about my age, many thanks for the reply 😀
BobDVolunteer
The risk assessment tool is known as CHADS2VASC2 and involves a number of co-morbidities. Blood pressure is one of those BUT it is important to understand that once given a score cann't be removed so for example normal blood pressure resulting from taking drugs for it still counts. With your profile it is highly likely that your score is well into "yes take them" area.
There are no projection tools regarding "stickyness" of blood though those taking warfarin are judged by their INR number which is not relevant with any of the DOACs such as Edoxaban which work in a different part of the clotting process. By the way stroke risk is not about sticky blood it is about clotting
Finally I would not agree with the cardiologist that your risk of stroke is low compared with bleed risk. His views do not match current thinking.
Thanks BobD are there any papers you can point me too which might show the current prevalent thinking if the cardiologist’s views are not current. I get very anxious when health professionals have different opinions. Hence posting here. Appreciate your taking the trouble to write.
actually Bob I have looked at the risk assessment tool, thanks for that and I ‘get it’ now and your comment that scores can’t be removed also very helpful. I don’t need to do more reading, I will go along with the GP.
If you have side effects you can't cope with then discuss a change of anticoagulant with your GP not all medications agree with everyone as we are all different and there are other anticoagulants out there which will give you an "easier ride" as regards side effects.
I understood that the criteria for prescribing anticoagulants at 65 or over was the same regardless of gender. I was 65 when first diagnosed with AF and went onto Warfarin immediately and apart from a short spell of 4/6 months with Edoxaban I have been on Warfarin since 2010.
Edoxaban, one of the newer anticoagulants did not work for me and successfully gave me many, continuous sleepless nights with the most violent and vile nightmares ever .... ever! My GP is one of the younger breed who has been indoctrinated into prescribing these NOAC's and I hand delivered my surgery a letter for her TELLING HER of my woes and stating in simple plain English that I intended to return to Warfarin which has given me a trouble free consumption. I self test my own INR ( which the surgery supports ) and I also tweak my own dose if the INR gets too high or too low. No problem with Warfarin at all and I have undergone several medical/surgical procedures including knee replacement surgery without any problems ( which has involved stopping and restarting Warfarin ) .......... why should I expect problems other than 'Big Pharma' mounting an anti marketing campaign against Warfarin.
Lets face it Warfarin ( Coumadin ) has been around for 60 or 70 years, unlike it 's newer partners in crime ( NOAC's ) it is well tried, tested and proven. I have to say I notice more and more peeps on this forum writing in about the side effects of these NOAC's. For me anyway, even diet isn't an issue either, be it food or drink consumption ( alcoholic and non alcoholic ).
John
Well said John. I recently started on Edoxaban; beware those considering this, the medics push NOACs hard instead of Warfarin for various reasons not all to the benefit of the patient eg saves hospital time??
I decided to accept my cardiologist pushing Edoxaban for two reasons I like a very varied diet & sometimes OD on certain things so balancing my INR with warfarin may have been an issue. Secondly, my anxiety levels are high enough already and a once a day pill should be 🤞OK. I hope I don't regret it!!!
Not quite correct; assuming no co-morbidities, the Chad score becomes 1 for a man on his 65th birthday, and 2 for a woman, who gets a point simply for being female.
well thats what I was saying but didn't go into all the detail. In other words if you have a condition at 65 that requires A/c ...you get it regardless ( unless a patient is dumb enough to refuse it ) of gender.
Ah but we get a point for the sin of being female! So at 65 our score goes up to 2 if we have no comorbidities.
That's correct woman do get an extra point but then somewhat incongruously the female threshold for requiring anticoagulant is also raised by a point. So oral anticoagulation is recommended for patients with a CHA2DS2-VASc score of ≥ 2 (men) or ≥ 3 (women).
Well it's not exactly the "sin" of being a female is it , it's just biology. The higher risk is associated with higher estrogen levels and that can be higher if a post menopausal woman's history has included pregnancy, birth control or the use of hormone replacement at any point in their life.The overall higher risk when excluding the elements of age and sex is higher in men than women but age and sex are important markers.
It basically "evens the score" as it were which is why both sexes are recommended and anticoagulant or antiplatelets depending on your full medical history and irrespective of lifestyle changes.
The point for being female is disputed. The latest guidelines from the European Cardiology Society do not take account of being female unless there are comorbidities so anticoagulation is urged for women if the score is 3. I have read somewhere that the Japanese do not award a point at all. As HRT is to replace oestrogen the ovaries no longer make either due to decline or removal how can that make the oestrogen higher? Birth control pills are different and can cause strokes in some young women. Your next sentence does not seem to make sense logically. How can you say that stroke is higher in men if sex has been excluded?
As for sin - I was being ironic.
I am really surprised by the attitude of your cardiologist. I do remember once someone saying Patients are frightened by strokes whilst Doctors by bleeds. We’d like to avoid both!
One always has to assess the benefit to risk between any medicine but your GP can also use another algorithim called HASBLED to assess the likelihood of a brain bleed, which as we age the risk can increase. When that happens the anticoagulant dose is often reduced. That all has to be balanced against the stroke risk, which for us AF’ers is more often much higher so unless you have a known blood disorder anticoagulants are your best friend.
Just personal experience, I had a TIA several months after stopping anticoagulants following 12 months free of AF after ablations. I couldn’t get back onto them quick enough. I’ve had, lately, a few falls one of which I hit my head, no brain bleeds, no noticeable difference in stopping minor bleeds and I have had several minor operations with no problems.
I am on Apixaban rather than Edoxaban - two reasons 1. Apixaban has the lowest brain bleed profile. 2. It is taken twice daily so the half life is half of Edoxaban. You have to remember to take every 12 hours but I feel more secure with that regime.
Hi there Saladmuncher.
It’s an interesting issue, and not as straightforward as some might suggest. If you are not ‘classified’ to an AF group and suffer eg a suspected TIA, a neurologist will prescribe antiplatelets (eg aspirin, clopidogrel) to avoid clot formation in the small vessels of the brain causing an ischaemic stroke. If you are classified to AF a cardiologist will prescribe anticoagulants, apparently to avoid clot formation in the heart travelling onwards to the brain. Indeed, NICE guidelines in the UK prevent the medics from prescribing antiplatelets for anyone diagnosed as suffering from AF of any kind. I infer your cardiologist to be saying in your case that very short duration AF episodes are less likely to lead to clot formation in the heart than anticoagulants are to risk causing a haemorrhage in the brain; whilst your GP is sticking firmly to NICE guidelines. If you are particularly worried about a haemorrhage whilst taking anticoagulants, you might try to ensure you take one of the anticoagulants that has an antidote (ie not edoxaban).
Since all of the UK NICE recommendations are based on risk analysis at population level, they cannot be tailored to individual circumstances. With only rare PAF episodes of 30-40 minutes, I have personally concluded that my own bleeding risk from anticoagulants currently outweighs my ischaemic stroke risk. I am not (yet) taking anticoagulants but am taking over-the-counter 75mg aspirin daily.
Don't hospitals in UK use the same reversal agent for edoxaban as apixaban? That's what I have read in the hospital protocols I have found online.
Here’s an example, but I’m no expert!
rightdecisions.scot.nhs.uk/...
Yes, but your protocol does mention considering Andexanet alfa for edoxaban reversal as an "off label" use.
In England the protocols I've read seem much more accepting of this "off label" use of Andexanet alfa for edoxaban patients, of which there must be thousands in the UK.
See the Walton Centre protocols for DOAC reversal. I tried to get a link for you, but only got a pdf downloaded. Search "Walton Centre doac reversal" and the first item returned is the link to the relevant protocol pdf.
Here's another article I found stored on my phone ...
"Reversal agents for current and forthcoming direct oral anticoagulants"
pubmed.ncbi.nlm.nih.gov/369...
A free full text pdf is available in the Abstract available. This includes edoxaban in a list of DOACs suitable for the use of Andexanet alfa as a reversal agent.
I would give more credence to a "cardio consultant" or a neurosurgeon, both of whom would have had much more experience of seeing the results of catastrophic intracranial brain bleeds than a GP, and so are perhaps more aware of these risks for individual patients.
As for stroke risks, the following article relates stroke risk to both duration of AF events and your Cha2ds2-vasc score. Especially note the red/green infilled table in the article ...
“Pill-in-Pocket” anticoagulation for stroke prevention in atrial fibrillation
onlinelibrary.wiley.com/doi...
Good luck.
As I’ve recorded here before, the EP who prescribed Flecainide for me, told me that unless an episode of AF went on for a considerable time with a heart rate of 140 or more, I was not at risk of stroke. I stopped taking them once the dose of Flecainide I take put an end to episodes and am still alive at 80 without having to put up with the dreadful effects the anticoagulants had on my digestion. And I am still free of episodes since I suggested slightly reducing the dose I take from 2x100mg to 50mg and100mg.
As has been said Apixaban has the lowest bleed risk, but a stroke is not to be treated lightly. As it's like Russian Roulette what piece of brain you will lose if you have one. I did not take the Apixaban I was prescribed by the GP because of my bleed risk worries and then had a stroke and was completely paralyzed down my right side. In retrospect I would not worry about the bleed risk because once you have a stroke you will have to take it anyway if you have any sense. I've been on Apixaban now for 9 years, since my stroke. It's the shape of the heart and the way it beats that causes clots not the "stickiness" of the blood whatever that may be.
All the best.
Roy
I probably used the wrong word. Whatever the correct word for more or less likely to form clots is was what I meant, but I don’t know a term for that. Thanks
According to Google it's anticoagulant. But that would not make sense either in your question as it would be saying the same thing twice.
All the best.
Roy
there are natural ways to thin the blood. Watch salt intake and hydrate constantly including during the night - only water though. Give up tea and coffee as they are not hydrating. Certain fruits and vegetables thin the blood too, lots of info online.
Anticoagulants do not thin the blood. They lengthen the time it takes to clot. None of your tips will stop an afib caused stroke just like taking aspirin won't. They might have anti aggregant effects but that is all.
Reducing vitamin k (very high in veg such as kale, chard and spinach) can help with blood clotting and there is a lot of research that certain fruit and veg also act on blood clotting. Hydration is absolutely key as well, I don’t think that is arguable.
You don't seem to understand the difference between anticoagulation and anti aggregation.
I'm assuming you have AF? I too have Af but not that frequently, I don't take anything, if as you say you have co morbidities, the more meds you take the bigger chance there is of some fight ing each other. Maybe have a medication review to see if you need all those you are taking. GPS are in the habit of just leaving meds on a prescription list that you no longer need but they forget to remove. The less you take the better chance your body has of coping.
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