I found these charts on a John Mandrola blog a couple of years back & took screenshots. I came across them last night when I was clearing up my photos folder & thought others might find them of interest, particularly those people worried about stopping an anticoagulant for a few days for surgery or a procedure. I think it puts things in perspective. Seems I’m only allowed to upload one at a time so I’ll do them separately.
Stroke Risk: I found these charts on a... - Atrial Fibrillati...
Stroke Risk
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HGates
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Here’s the 2nd
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That's an excellent explanation 👏 thank you
Remember that this risk is per year so multiplies.
Yes of course. I just wanted to demonstrate how unlikely it is that a few days off an anticoagulant will cause any issues.
Hi
But my friend with MS and a manmade valve ran out and didn't take them with her to her farm 20kms awa where she had a 'retirement village home" too . She had visitors, sisters from overseas.
It was on Day 8 she was rushed to hospital with a mild stroke.
She was 81 and on PRADAXA 110mg x twice day.
Food for thought.
cherio JOY. 75. (NZ)
Sorry to hear that. I was concerned when they took Dad (83 at the time with 17 years of permanent AF) off warfarin for 10 days when he was hospitalised with pneumonia. Luckily he was fine. I guess, as you say, it does happen but thankfully it seems rare, particularly as most procedures require only a couple of days off an AC.
Hi
With a CHAD Score of 5, I'm not entitled to an opinion.
I had one heart specialist who decided to 'check up " on my supplies. We got into an argument as 1 of my supplies of 3 months was not showing. Later I went to the chemist and got the printout and had it placed in my file.
Goodness me he didn't believe me.
Even 3 ops over 3 years moves my supply from usual months.
Cherio JOY. 75. (NZ)
What's with ) Positive Rhesus Blood Group. My Mum had that. I ended up with A Negative from 2 x positive parents. "It makes me 'a longer further away descendant from a monkey!"
Gosh 3 ops in 3 years is tough going. Hope you’re doing well now. I too am A negative but I had no idea about the monkeys!
Hi
The RHESUS factor is from monkeys.....
Rhesus positive you are closer to the monkey profile than if you are negative.
Have fun with that.
I guess that is why trials - of different sorts are compared with them.
I wonder if monkeys get AF?
cherio JOY. 75. (NZ)
Hi
Unfortunately these 3 needed doing....
2020 Thyroidectomy.
2022 Johnson & Johnson horrible mesh out which was transmoving and causing damage.
2023 Right shoulder (3.1/2 wait) with 1/2" spur which had developed, almost full tear (made full) and bicep unattached. Done through 2 holes.
The first was tricky with a rapid heart beat and persistent AF. Tues - Sun stay.
I had 2 anaesthetists. ..2nd one 2 doctors and 2 anaesthetists. H/Rate just controlled by Diltiazem. Overnight
3rd one private via ACC footing the bill. 1 of each overnight.
What with keeping me warm, bed moving, and drips etc I survived.
cheri JOY.
Pleased to hear all ended up OK Joy. A lot to deal with in such a short period of time.
Hi
I feel as if I can clearly outline my frustrations with meds and clearly know why the upcoming repeat of CT Scan.
But I have asked a question. Do I stop the thyroxin on the day or 2-3 before mornings. I was told that a nurse would ring me. Still waiting.
cherio JOY
Especially if you have O Positive Blood as I have.
Is there something particularly good or bad about being O Positive?
Hi
It is used as a common denominator in blood transfusions as it can be used for negatives astonishingly.
Mum was called up to give blood regularly.
cheri JOY
Yes thinner blood and less clots. More bleeding if on blood thinners so not so good.
You Goggle the various blood types on line. I have been giving blood since I was twenty years old, some 58 years ago. My Nephew is a stroke consultant in the UK also.
Thanks for those informative presentations of information which do illustrate that the stroke risk from not taking an anticoagulant for a few days is very low. Also that being on anticoagulant doesn't fully eliminate stroke risk. At the same time Afib is a long term condition and presenting the same information over a period of one or two decades would see very many more reds on the charts. Taking your two slides together would it be correct to say that with a chad2vas score of 2, 17 people out of a 1000 would avoid a stroke if anticoagulated but 12 people out of that 1000 would suffer a major bleed? So with a chad2vas score of 2 you are statistically safer on anticoagulant than not. If the chad2vas score is 1 then the stroke risk goes down and in such circumstances the risk from stroke v major bleed is much more finely balanced and therefore not a straightforward decision. Good information and thanks for posting.
Thinking positively about outcomes, the charts above compounded over 10 years indicate that 77% of affibers will not have a stoke even if they do not take anticoagulants. 92% will not have a stroke if they do take anticoagulants. They are of course clearly beneficial. A stroke can be devastating.
Indeed. Of course this is just a demonstration for chadsvasc 2. Once someone is ticking nearly all the boxes on the scale their risk is substantially higher.
Also keep in mind that these predictions are based on the premise that everyone with a CHA₂DS₂-VASc score of 2 has the same stroke risk. It does not take into account other variables, such as afib burden and event duration.
A more recent article by Dr. John Mandrola entitled AF Duration? Another Big Story from 2023 talks about some changes in thinking based on newer trial data.
An exerpt -- For an older patient with stroke risk factors and 3 hours of AF on a cardiac device, pre-2023 thinking would have us leaning toward anticoagulation. The results of the ARTESIA and NOAH-AFNET 6 trials strongly question that idea.
Jim
Yes there’s been so much conflicting data on that one over the years. I do think that the studies like the ones you mention that are not performed by drug companies wanting to demonstrate the huge benefit of their drugs (occasionally by using some subtle jiggery pokery) are particularly interesting. Often doctors are making decisions based solely on the results of drug trials & it takes further research like this for them to question their protocols. Of course, as JM also points out, by the time you’re into your 80s or 90s AF is just one of many potential causes of stroke & anticoagulation is not a ‘cover all’ blanket.
Well said. Emerging data from studies independent of the drug companies are certainly questioning the wisdom of only relying on the CHA₂DS₂-VASc score and pointing to a more individualized approach, taking into consideration other variables as afib burden and duration of episodes.
Jim
How do asymptomatic a fibbers fit into the picture?
I would think AF symptoms not to be relevant given that the source of the micro-thrombi are postulated to arise in the left atrial appendage (LAA) during AF episodes and to be caused by clotting changes and turbulence in the blood flow within those who have a particular shaped LAA (i.e. "cauliflower shaped").
Steve
Thank you. It's just that it seemed to me that many sufferers have never been diagnosed and are unlikely to be taking an anticoagulant and have not been factored into the studies.
Ah yes - I misunderstood your point, and it's a good one. Silly me. My apologies.
Also of interest is that when we read of the risk of stroke and especially of death from AF, I gather the majority of morbidity is in the population you were referring to, viz. those who are undiagnosed owing to their AF being symptomatic (or at least that their level of symptoms do not cause them to seek treatment).
That's interesting.
Steve
Are you talking about their risk factor versus symptomatic a fibbers? Or are you talking about the fact, they may not know what their real a burden is, including duration of episodes?
I don't have any information on the former, but my guess is your stroke risk is similar to those with symptomatic a fib. But maybe not. Very interesting question.
If you're referring to the latter, that that's one reason trials like REACT-AF use watch monitoring document episodes.
Personally I've always had fast afib which is symptomatic to the point that I know when I have it.
How can I be so sure? I guess it's over 30 years experience, with numerous EKGs, including two home devices being the car and Apple Watch. On the watch, I can track my AFib burden several ways, including by rhythm and also by heart rate alone.
Could I have had a short asymptomatic, sometimes called subclinical, a fib episode along the way. Sure anything is possible, but the data is now suggesting that those short sub clinical episodes may have no influence on stroke risk.
Jim
Thank you, I was thinking more along the line of the undiagnosed, whose condition is often only uncovered after a Post Mortem. I suppose i'm muddying the waters!!!!
I’m not sure you could make the waters muddier! There is so much more research that needs to be done on AF. Ppipman also raises an interesting point about LAA shape potentially being an independent risk factor.
I'm asymptomatic, but diagnosed. Obviously if you're undiagnosed you're not on this forum - unless you're a bit weird
I am subject to the same chads2vasc stats as anyone, presumably more so as my heart is misfiring 24/7 unlike paroxysmal folk who suffer worse ( IMO) but periodically.
The problem is there seems to be studies to reinforce all perspectives. Dr Sanjay Gupta (York Cardiology) on YouTube has a video called ‘Why I don’t believe Afib causes strokes’ naming studies that reinforce his opinion that it IS the chadsvasc that is vital NOT the AF duration. The studies seem well done & he’s very convincing. I went through a period of reading every study I could find on AF & the only thing I ended up certain about was that the conclusions were all over the place & uncertainty still reigns supreme.
Gupta's video predates some of the newer research that afib burden and duration may be important. The ongoing. REACT-AF trial will be further testing these different premises among other things.
Jim
I hope so because I’m not sure I’m a believer that newer is better. Research is research after all. It would just be nice to get some consistency though.
I’m not sure I’m a believer that newer is better. Research is research after all.
Respectfully disagree here. For example, when Gupta was googling on his Youtube video, some of the newer mentioned papers did not exist and therefore his conclusion was not based on current knowledge.
Jim
Perhaps it could be argued that they’re not actually reaching different conclusions. Establishing anticoagulants offer little benefit to those older patients with short duration sub-clinical AF does not actually counter the idea that AF itself is not the cause of stroke. The React-AF trial will be interesting.
TracyAdminPartner
Good afternoon, thank you for your post, may I also highlight our resource ' that highlights the CHADVASc table and the importance of anticoagulation lowering the risk of an AF related stroke.
UK and International: api.heartrhythmalliance.org...
US: api.heartrhythmalliance.org...
Kind regards
TracyAdmin
booklet
kind of you to share this. Thank you
Thank you very much for sharing this information……I’m sure it will give some people reassurance if they need to stop anticoagulation for a few days.
To add to that, I have read studies that show that the majority of the micro-thrombi form only inside what is called a "cauliflower-shaped" left atrial appendage (LAA). This is one of three shapes of LAA and is a feature of a minority of individuals. I wonder what would happen to those figures if that were accounted for?
I would also think it possible that one day, when suitable technology is available, rather than anti-coagulate us all at great cost and some risk, only those with a risky LAA will be offered anticoagulation or even to have surgical closure of their LAA.
If I recall, there is even evidence to show that the stroke risk for those individuals with that risky LAA might be independent of their having AF, i.e. that the arrhythmia itself is not causing the turbulence in blood flow or changes in clotting factors that predispose to clots forming.
Steve
This is a really good point.
I suppose it is difficult to image the LAA or it would be done? Perhaps, too, the evidence for clot formation in those cauliflower-shaped LAAs isn't conclusive. I'll do some more Googling!
Steve
Can they not seeit with a cardiac MRI?
I don't know but would think so. It seems odd that it receives such little attention. I shall Google away to find out more!
I hope La Belle France is treating you well! We hear such negative news about France politically but I am sure it is twisted and tweaked!
Steve
Things are not that good here but at least we have a government at the moment even if it does fall over the Budget! It does take much longer now to get medical appointments. I rang up for my mammogram last week and can't get a slot till mid Feb. Here in the sticks we are enjoying a glorious Indian summer with shade temperatures in the mid 20s and 40° in full sun on our sheltered south facing balcony. Having spent last night in afib I feel a bit wiped out today so have been lounging in the sun reading.
Well, having AF where you are is definitely rather better than having AF here! 
I would be having a fine glass of some luscious red wine on that balcony!
Steve
Hi there !
Just one more thing ...more muddy !..
I wonder if the anticoagulant effects morbidity in some other way ? (other than stroke)
that we dont know about yet? with its long term side effects plus quality of life etc !! ?
Does it matter that these charts don't differentiate between paroxysmal, persistent and permanent and their many variations...
No. the evidence has always suggested that it doesn’t matter how much or how little AF you have, your risk is dependent on your chads2vasc score. Mjames1 highlights a couple of recent studies that have shown little benefit of anticoagulants in older people with very short duration AF & it seems that further research is taking place on this but at the moment, for the most part, the type of AF is still ignored when calculating risk.
I'm sure you are aware of the following article that includes both chads2vasc score and max daily duration of AF in the coloured (red/green) risk Table included ...
“Pill-in-Pocket” anticoagulation for stroke prevention in atrial fibrillation
onlinelibrary.wiley.com/doi...
I would be interested in your thoughts on this article and the different risks shown.
Lewis1234
This is the study that mjames1 mentions. It looks like they’re going to be enrolling a large number of participants so the results should be interesting. I see the article mentions another big RCT that was conducted on PIP anticoagulants called IMPACT that failed to show benefit. They’re definitely justified in saying warfarin is hardly ideal as a PIP though! The observational data they reference certainly seems to show that duration of AF, particularly when combined with a moderate chads2vasc score increases risk so it sounds like this may be a pivotal trial. They’re going to need people with very very infrequent AF though as they are going to have to take the AC for 30 days after each episode lasting longer than an hour. Anybody with a monthly 2 hour episode need not apply. I have to say I remain sceptical but it would be a hugely welcome result to those with a very light AF burden if this trial proves successful.
I take apixaban because I’ve seen personally in a family member how a stroke can take away someone’s independence. While I remind myself that bruises, blood shot eyes and upset stomachs are manageable they can be frustrating. Though sometimes I can’t help not thinking about being part of that small group in 1000 who experience a serious bleed or a stroke —someone will be. I know anticoagulants are backed by strong evidence, but the choice to take them is still complex. Saying that, I do take a DOAC each day, but I hope ongoing studies will clarify this tough decision. As I read about new anticoagulants still in trials that may further reduce bleeding risks, this is particularly important—not for those who are confident in their decision to take them or those who are certain they will not—but for those in the middle glancing at the black box warning on their tablets and looking for better future options in anticoagulant care.
my husband had a massive stroke last year after his ablation unknowingly had failed a few years later. If he had been on blood thinners this would never of happened . His AF caused the stroke . Two clots hd travelled up to his brain in his sleep
How awful. Sorry to hear that. Assume he was very low chads2vasc for the EP to take him off anticoagulants?
I’m not sure . He was never out in thinners after his ablation well onky the first few weeks . I took him to A and E two days before his stroke l with an extremely high heart rate and he still wasn’t put on thinners . The chad score was low for some reason even though his AF history should have shown red flag for stroke risk . Not sure why they didn’t put him on thinners . They said his age 64 but this shouldn’t have been a reason to give him s low score with his AF history
Sorry don't understand what you are saying. Is it that you are at more risk of a stroke with an anti coagulant. I must have b een one of the unlucky ones.
No the chart shows that if 1000 people with AF & a chads2vasc score of 2 took no anticoagulant for one year, on average 25 of them would have a stroke in that period. If all 1000 had taken an anticoagulant for the year, 17 of the 25 would have been saved from a stroke.
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