Eliquis and nosebleeds - FYI

This is a caveat for those taking Eliquis. Plan ahead for how you would manage a nosebleed in
case you would have one.

Now that we have winter in some areas, humidity is low and definitely can dry out nasal tissues;
and for some, that can lead to fragile nasal capillaries; and if they rupture, you’re in for a bloody mess.
It’s also a reality that at my age, tissue tends to be more dry and fragile so younger people on
Eliquis may not have nearly the risk factor that ‘seniors’ do.

My nasal tissues have always been sensitive and at least 30 years ago, I had a
series of nose bleeds for which the remedy was to ‘zap’ the weak nasal capillary
by electrocautery. That held well until I began Eliquis in August 2014 in preparation for
my second ablation. Almost immediately, my nose bled on just one side, fortunately.
I can’t imagine coping with both sides at once. Dr. Natale’s nurse said I needed to get
that fixed pronto because if it flared during the procedure, they’d have to stop.

So I immediately saw the ENT who did a quick swipe of the right side with a Q-tip saturated
with silver nitrate. It’s not the most pleasant experience and didn’t work so I had an urgent
repeat treatment which did work…. until just this past weekend. I sneezed and blood
started oozing from the trouble side and even on half-dose of Eliquis, it was a gusher
like I've not ever experienced previously. Good thing I don’t faint at the sight of a lot of blood!

I packed that side with a cottony gauze I cut in a triangle shape to fit the nasal passage
and that filled up immediately and blood ran out like a faucet. I prepared another packing and
this time saturated the gauze with a wound sealant which contains aluminum sulfate (Nick Relief).
In hindsight, I probably didn’t do myself any favors putting aluminum so close to my brain, but
‘desperate’ measures….. It worked rapidly and the bleeding stopped.

Since it was the Christmas weekend, I decided to go to the ER just to be on the safe side….
not wanting to try to be treated on Christmas Eve or Day. The ER doctor removed the packing
and could see no suspect vessel… so discharged me and said to see the ENT in 3 – 5 days.
If it had been actively bleeding, they would have packed it but would not do the chemical cauterizing.
So then, on Christmas Day… the ‘gusher’ surfaced again and I managed it quickly.

Yesterday, I saw the ENT who once again cauterized the vessel with silver nitrate…. and
said to be mindful of the humidity factor in the house. I increased the furnace humidifier
a bit and hopefully, that will help. I have always ‘lubricated’ the nasal passage with a saline gel
solution (Ayr), that helps moisturize dry nasal tissue, but apparently is not enough.

I called the nurse today to report my latest events and she said to give it some time while the
cauterized vessel toughens up and to keep the area lubricated to retain moisture.…which
I had also been doing. No bending over or heavy lifting. Later on today, in another event,
more blood was gushing from the same nostril. Packed again and hoping for some permanent
relief soon. Sigh.

So, I’m posting these details as an alert to those on Eliquis so you can be aware if you do have
a nosebleed, it’s probably going to be very messy and inconvenient. It is also a very sobering
reminder about the potency of Eliquis and if you have an accident, fall or other trauma, it’s a grim situation.

Take preventive measures to keep nasal tissues moisturized with a natural oil such as coconut or sesame
seed etc. Don’t use Vaseline or petroleum-like chemicals that would be inhaled into lung tissue
as that can cause other problems.

I’m keeping my fingers crossed for this nasal capillary to toughen up quickly.

Jackie

Good info. I spent 15 years in EMS so saw a lot of nosebleeds. I've seen more than one house that looked like a murder scene due to a simple nose bleed that had continued for hours. You're right that winter is prime time for them due to the dry air. Count yourself lucky that you're not on home oxygen. That makes the problem much worse because the O2 being blown up your nose is bone dry coming out of the tank

A humidifier is the best thing you can do for yourself. Get one.

When a nosebleed happens, lean your head forward and pinch your nose closed. Hold it that way for at least 15 minutes. Yes, you'll end up with a bunch of coagulated blood in your nose but coagulation is what you want. If you lean back it will drip down your throat, won't stop, and it will eventually make you nauseous from swallowing it.

Eliquis isn't special in this regard. Any of the anticoagulants, including warfarin, will have the same effect.

Thanks, Carey. I do all that you've suggested given my history of nosebleeds. The ER MD gave me a packet of instructional information that confirmed my protocols and yours. He also gave me a couple of plastic nose clamps to try as well.

With the last event yesterday, I decided to use one of the essential oils I rely upon for what seems to be 'magic' first aid and applied Helichrysm EO with a small amount of coconut oil as a carrier and it worked like magic to stop the bleeding....at least so far. I'll continue applying that for a while to help with the healing process.

Yes, of course, it's not just Eliquis but all anticoags and undoubtedly "senior" nasal tissue as well coupled with dry air.

Jackie

Jackie:

Have you stopped taking Eliquis? Seems like the docs would have said to stop, years ago when I was taking Coumadin I got bloodshot eyes and my thumb had a sack of blood, my doctor said to stop taking Coumadin. My mother was on Coumadin and after a few years she had black stools, (blood) her doc. said to stop the Coumadin.

Liz

Liz - because of the LAA isolation, even though my TEE clearance velocity is normal, it was felt that I should remain on half-dose of Eliquis. Probably has to do with age as well.

Jackie

Jackie

I guess I don't understand, you had 3 ablations and your tee clearance velocity is normal you still have to be on Eliquis, you have gone through a lot and still are at risk for a stroke?

Liz

Quote
Elizabeth
I guess I don't understand, you had 3 ablations and your tee clearance velocity is normal you still have to be on Eliquis, you have gone through a lot and still are at risk for a stroke?

Her CHA2DS2-VASc score would be important in the decision. She's at least a 2 and that's enough to consider anticoagulation. Throw in the isolated LAA and it becomes a pretty good argument for continuing the AC.

Liz - yes - as Carey mentions... depending on the CHADs₂ Risk Chart - since I'm 81, I either have 2 points for age or 1 plus another point for being female. I don't have any of the other markers such as hypertension or diabetes. But the main influence is the LAA isolation. I also have a slightly low platelet count that causes longer clotting times so that's another complication for me with anticoagulants.

While the nosebleeds are very inconvenient, I'm totally delighted with my peaceful heart in NSR and the mental and emotional relief of not to have to think about managing AF so I'm enjoying every moment.

I just wanted to alert anyone on the anticoags to plan ahead for how to manage a nosebleed because it certainly is a mess and darn inconvenient....especially if one started when away from home.

My home remedies seems to be helping and the chemical cautery area also seems to be working.

Fingers crossed! Next week I'm going to cautiously get back to my typical activity level to start the New Year.

Jackie

Jackie:

Thank you for your reply--from what I have been reading problems with the LAA is because of long standing persistent AF, you didn't have that, and it seems you are on the low end of the CHAD score . It isn't just because of age but in what shape is your body in, I also have low platelets. Hope you are better that wasn't a very good Christmas present.

Liz



The Cardiology Advisor >
Topics >
Stroke >
Left Atrial Appendage Isolation for Stable Sinus Rhythm


May 15, 2017

Left Atrial Appendage Isolation for Stable Sinus rhythm


LAA isolation was achieved after a mean of 2 procedures.
LAA isolation was achieved after a mean of 2 procedures.
Electrical isolation of the left atrial appendage (LAA) helped promote stable sinus rhythm in patients with paroxysmal and short persistent atrial fibrillation (AF), according to research presented at the Heart Rhythm Society's 38th Annual Scientific Sessions, May 10-13, 2017, in Chicago, Illinois.

Although pulmonary vein isolation is an effective treatment strategy for paroxysmal AF and short persistent AF, ectopics from the LAA can trigger AF. Therefore, investigators sought to assess long-term follow-up and incidence of embolic stroke and LAA thrombus formation after LAA isolation in 71 patients.

Continue Reading Below

Pulmonary vein isolation, left atrial isthmus line, anterior line, complex atrial fractionated potentials, and roof line were among the ablation strategies used. LAA isolation was achieved after a mean of 2.0±1.0 procedures.

A total of 30% of patients (n=21) remained in stable sinus rhythm after a mean follow-up of 63±30 months. However, after 21±20 months from the initial procedure, a further catheter ablation procedure was performed in 72% of patients (n=51).

About half the patients (46%) remained in stable sinus rhythm after a mean of 1.5±1.2 procedures and 46±20 months of follow-up.

Embolic stroke occurred in 18% of patients (n=13) and LAA thrombus formation was discovered in 17% of patients (n=12) on oral anticoagulation.

“[A] high incidence of embolic stroke and LAA thrombus formation was observed despite sufficient [oral anticoagulation] therapy,” the researchers wrote. “Therefore, LAA isolation should be taken into consideration due to moderate benefit and potential risk of embolic events in clinical



Edited 1 time(s). Last edit at 12/31/2017 02:00PM by Elizabeth.

I will be 60 in Feb. I am on a blood thinner for life after my second Ablation required LAA isolation. My velocity is great but I have no A wave after the LAA isolation. I do hate blood thinners but Dr. Natalie determined I needed OAC for life.
I bruise so easy and my skin is so soft I skin easy
I do like being in NSR. 👍

Smackman::

I thought after LAA isolation you would not need blood thinners, didn't Shannon have that done and no longer takes blood thinners?

Liz

This article answers most of my questions:

Compared with patients who had only the standard procedure, those who also had LAA isolation were almost twice as likely to be free of AF at 1 year: 56% vs 28% (hazard ratio 1.92; P=0.001).

Among patients who continued to have atrial fibrillation, 62 patients (27 in group 1 and 35 in group 2) had a repeat ablation that included LAA isolation.


At 2 years, 76% of patients who had received standard ablation plus LAA isolation at baseline vs 56% of patients who had received only the standard procedure at baseline were free of arrhythmia (hazard ratio 2.24; P=0.003)


Transesophageal echocardiogram tests from 93 patients who had undergone LAA isolation (85 in group 1 and eight in group 2) showed that 48% had preserved ejection fraction, but 52% had impaired function, including slow LAA peak-flow velocity.

Four patients (4.5%) in the standard-ablation group had a stroke. No patients died. One patient in each group had pericardial effusion, and one patient in the standard-ablation group had gastrointestinal bleeding.


The study showed that pulmonary-vein triggers of AF are important in paroxysmal AF, but in longstanding persistent AF they are less important and LAA is more important, Di Biase noted. However, further studies are needed to determine the physiopathology behind these findings, he said.


Hindricks suggested that the study would have been stronger if the LAA intervention had not been performed in the control group. Also, he wondered why the stroke rate was so high in patients who did not undergo LAA isolation. Di Biase replied that the strokes occurred in patients who were not compliant with taking anticoagulants.

Session comoderator Antman wanted to know: "Are you prepared to stop the anticoagulant? How would you decide?"


Di Biase replied that according to European and US guidelines, anticoagulants should not be discontinued for patients who have a CHADS2 score of >2—which was the case for about 50% of the patients in this cohort. These patients, whether or not they had LAA isolation, should be on oral anticoagulants.


"These are patients that do not come to the [electrophysiology] table because they had to discontinue anticoagulant, they came to the [electrophysiology] table because they benefit from sinus rhythm," he said.


The study was sponsored by the Texas Cardiac Arrhythmia Research Foundation. Di Biase is a consultant for Biosense Webster, Stereotaxis, and St Jude Medical and has received honoraria/travel expenses from Biotronik, Medtronic, Boston Scientific, and EpiEP.

This is one hxll of a disease, darned if you do and darned if you don't, at least for me.

Liz



Edited 1 time(s). Last edit at 12/31/2017 06:52PM by Elizabeth.

Quote
Elizabeth
from what I have been reading problems with the LAA is because of long standing persistent AF

Nope. I have an isolated LAA and have never had LSPAF.

Liz - keep in mind that typically, when blood thinners are required after an ablation on a continuing basis, the ablation procedure often involves isolating the Left Atrial Appendage. This is an area that is not commonly evaluated by EPs who have not had advanced training to treat those related areas. When these ‘new frontier’ areas are not routinely assessed during the ablation procedure, then it’s not uncommon for the patient to go back for repeat ablations…which continue to be ineffective because the trouble areas aren’t being managed. However, if the appendage is isolated, then for a period of time, anticoag therapy is required. For some, it's long-term.

Eleven years after my first procedure and when I developed a-flutter, I knew that most likely when I went for the second ablation in 2014, it would involve LAA isolation… and it did - along with ablating several other areas.

So if the LAA isolation procedure leaves the clearance velocity below what is considered a safe range or marginal, then anticoagulants are required to prevent clots from forming in the appendage. The patient’s age and overall risk factors are also considered in the assessment.

As Shannon has mentioned in other posts regarding trials on the Watchman and Amulat implant devices that occlude or seal off the appendage via natural tissue endothelialization, this procedure is recommended to eliminate the life-long anticoagulant therapy. Yes, it involves yet another procedure, but once done, that should be the last one. You may recall Shannon’s saga with the Lariat procedure followed by the Amulat implant which now allows him to be free of anticoag therapy for life.

Jackie

I have an isolated LAA and preserved ejection fraction post 6 months Natale ablation. I was given the OK to stop Eliquis and take a baby aspirin, or go on half dose Eliquis.

I’m awaiting the answer to my question as to the morphology of my LAA before making any changes. As the expression goes, ain’t no thang like a chicken wang.

Should I choose the daily baby aspirin I will also have to do an NSAID challenge test because of a severe NSAID allergy that I almost died from. Unclear right now If aspirin is safe for me to take. The path is rarely clear cut. I would like to be free of Eliquis, but how high is the risk of stroke vs. a bleed? My CHAD is currently a 1.

A b Page;

Gosh, it is always something, one would think that going through all that you have and also others that you wouldn't have to take any blood thinners.

I remember when Hans Larsen went to France to have his ablation, I don't recall him saying that he would have to take a blood thinner afterwards for perhaps life. So having the Watchman done would alleviate the need for taking a blood thinner, I haven't read too much about that procedure I know that Shannon had some problems afterwards but is ok now.

Liz

Quote
Elizabeth
I remember when Hans Larsen went to France to have his ablation, I don't recall him saying that he would have to take a blood thinner afterwards for perhaps life.

A successful ablation that didn't require isolating the LAA won't require anticoagulation if the patient has a low enough CHADS score, and the vast majority of ablations don't involve isolating the LAA. But if you're a CHADS 3 or above, anticoagulants are going to be recommended even if your ablation was 100% successful. People tend to overlook the fact that a large number of people with a history of afib have strokes without having experienced any recent afib episodes. Afib creates an environment that favors clot formation even in the absence of arrhythmia.

And to be clear, a successful ablation means 100% NSR without antiarrhythmic drugs 1 year post procedure. It doesn't mean NSR maintained by drugs, as some EPs seem to be fond of defining it. Any atrial arrhythmias after the blanking period = an unsuccessful ablation.

Carey:

I have a book written by Hans titled "Thrombosis and Stroke Prevention", it was written in 2005. I realize more info. on the this subject is out there, but this is from his book:

A group of American researchers evaluated stroke risk among 700 elderly participants (mean age of 75 years) in the farmingham Heart study and concluded that afibbers with a predicted annual stroke risk of 2% or less (irrespective of age) may not realize additional benefit from warfarin compared with aspirin and their risk of stroke may not exceed the risk of life-threatening bleeding with warfarin. Thus anticoagulation therapy may not be justified in individuals with low predicted rates of stroke.

The increased stroke risk associated with atrial fibrillation is clearly linked with embolic rather than thrombotic stroke and, more specifically, with embolic stroke caused by thrombi originating in the heart (cardioembolism). The risk of an atrial fibrillation associated stroke is markedly increased in the presence of certain well-defined risk factors which are: Hypertension, diabetes, heart failure, left ventricular ejection fraction below 0.35, coronary artery disease, presence of prosthetic heart valves and hyperthyroidism.

To further complicate matters, there is emerging evidence that it may not be the presence of afib as such that increases the stroke risk, but rather the combination of atrial fibrillation with one or more of the above risk factors (comorbid conditions) which, in themselves, are known to be associated with a significate increased stroke risk.

Liz

Okay, Hans wrote that a full 12 years ago, so yes, a lot more is known now, but what you just quoted pretty much confirms what I just said so he was correct in his thinking then.

AB Page....…. I truly hope your appendage anatomy is one that allows you the most freedom from anticoagulants.

As for taking aspirin or other NSAIDs, I strongly encourage you to research very thoroughly the negative impact (long term) of these chemicals on gut health.. both stomach and intestines and also long-term use risk for stroke-related bleeding into the brain. There is significant support that LT use has a variety of downsides. You don’t want to trade one issue for another… especially one that could result in having to take other meds as a result. Spend a considerable amount of time doing this research as there’s a lot to compare.

Those medical professionals who have advanced education and certification for practicing functional and restorative medicine tend to avoid aspirin/NSAIDs in favor of “natural” blood thinners such as a combination of specific Omega 3’s, Vitamin E, Ginkgo biloba, Pycnogenol (or Maritime Pine Bark), enzymes like nattokinase and serrapeptase and even magnesium has some anti-platelet aggregation properties. Read about the properties of each natural remedy and if it says not to take in combo with aspirin or other blood thinners, that’s a tip that it has significant anticoagulant properties as well.

Ultimately, the goal is to avoid further complications with heart issues; move on and enjoy life.
I certainly wish you success in finding a solution that is specific to your needs.
Best to you,
Jackie

Quote
Jackie
AB Page....…. I truly hope your appendage anatomy is one that allows you the most freedom from anticoagulants.

As for taking aspirin or other NSAIDs, I strongly encourage you to research very thoroughly the negative impact (long term) of these chemicals on gut health.. both stomach and intestines and also long-term use risk for stroke-related bleeding into the brain. ...there’s a lot to compare.

Ultimately, the goal is to avoid further complications with heart issues; move on and enjoy life.
I certainly wish you success in finding a solution that is specific to your needs.
Best to you,
Jackie

Thanks Jackie, I appreciate it. I'm more of a technologist and artist than I am a scientist, so understanding and interpreting the research is hard for me. I'm still waiting to be told what my LAA morphology is. I have great faith in TCAI and Dr. Natale. It seems a low dose daily aspirin vs. Eliquis and it's inherent long-term risks heavily tip the scale towards a baby aspirin. I know if I was to take ibuprofen I would be in life threatening anaphylaxis in moments. I unknowingly took aspirin the day after paramedics saved my life in the last century, and I was fine, so I'm hopeful the option will at least be there. And if it's not, I'll have to decide between half dose or no dose Eliquis or an alternative you shared. And as it stands, I have Natale's OK to safely stop Eliquis, and his guidance weighs at the top of my list. Thanks for your help. As I said, the path is rarely well-worn or decisive, for any of us.

ABPage - That's very good news. I agree about Dr. Natale's guidance being at the top of your list and it should be most encouraging for you. That said, you can certainly look into adding a low dose of one of the natural thinners for a bit of extra insurance. Feel free to send me a PM if you'd like to explore in more detail the properties of the common choices.

Have a Healthy and Happy New Year!
Jackie

Quote
Jackie
Have a Healthy and Happy New Year!
Jackie

Thanks, and to you and everyone here.

There are side affects to blood thinners as well, bleeding in the brain, bleeding as my mother had in her gut. There are side affects with most drugs you take so to say one is safer than the other is just untrue.

Liz

Quote
Elizabeth
There are side affects with most drugs you take so to say one is safer than the other is just untrue.

Huh? What's untrue is a broad statement like that. Just because all drugs have side effects doesn't make all drugs equal. It's quite often possible to demonstrate that one is safer than another. I can think of a dozen examples right off the top of my head. (Vioxx vs. aspirin, anyone?)

What's not possible to demonstrate is the safety of non-prescription supplements since they are rarely, if ever, subjected to clinical trials.

Believe it or not, there's a large number of published clinical trials on many nutritional supplements but we are not likely to see them published in mainstream media unless you're reading at the website of a nutritional expert or a place like Life Extension Foundation, Townsend Letter, Weston Price Foundation, etc. monthly reports and magazine or websites like the Cochrane Library data base or similar...so, you're not likely to read about the successes... and we all know why!

Also, nutritional studies are often footnoted in abundance in books published by well-known functional medicine-type practitioners such as Doctors Mark Hyman, Richard Moore, Russell Blaylock, David Brownstein, Thomas Levy, David Perlmutter, David Brady, Stephen Sinatra, and on and on whose focus is on restorative, nutritional medicine and enlightening the public about safe, natural remedies for common health problems that don't require Rx drugs that often have side effects.

But, you can find comparison studies on drugs that do indicate one may have fewer side effects or a lesser negative impact than others in terms of efficacy.

Jackie

Quote
Jackie
Believe it or not, there's a large number of published clinical trials on many nutritional supplements but we are not likely to see them published in mainstream media unless you're reading at the website of a nutritional expert or a place like Life Extension Foundation,

I don't care if they're mainstream or not. I care that they're peer reviewed and that the publishing source doesn't have a vested interest in what they publish. And by peer reviewed I mean reviewed by people with the scientific training and experience to properly judge scientific studies prior to them being accepted for publication, and then followed up by replication of the studies by others in the field. Most of all, I care that it's sound science and not trials rigged to produce the desired results.

That's what you'll find very, very little of when it comes to non-prescription supplements. What's out there is largely anecdote, shoddy studies, blatantly biased studies, very little objective peer review, and virtually no attempts at replication.

And everything has side effects. Everything. Just because somebody labels something "natural" doesn't mean it's safe, effective or lacks side effects. Calling something natural also doesn't make it not a drug. It's a drug just as much as anything Pfizer or Merck makes; it just doesn't require a prescription, isn't FDA regulated, and isn't subjected to mandatory clinical trials, safety trials, post-market monitoring, and purity standards.

I'm not saying safe, effective non-drug supplements don't exist. They do. I'm just saying the science on them ranges from dismal to non-existent.

Interesting take, Carey. Who do Universities and Medical Journals rely upon for a lot of their funding?
Do pharma in house research publish all their results now? They didn't with vioxx (since you mentioned it).

Carey:

{Calling something natural also doesn't make it not a drug. It's a drug just as much as anything Pfizer or Merck makes; it just doesn't require a prescription, isn't FDA regulated, and isn't subjected to mandatory clinical trials, safety trials, post-market monitoring, and purity standards.)

Ha, ha, ha. FDA regulated--just like Aspartame-Nurta sweet, known by the regulators in the FDA to cause brain tumors, yet in 1982 the FDA approved those two. Do you know how the great FDA did that, Donald Rumsfield, who used to work there, then became the Sec. of Defense under Reagan, Rumsfield used his political pull rather than scientific means to get Aspartame-Nurta sweet approved. So if you have faith in the FDA as a scientific, purity standard and safety trial think again.

Liz

Carey - I totally agree about published studies and the reliability factor since they can be manipulated to favor the results and as we well know since that occurrence is very real and is should certainly of be of great concern, but unfortunately, it's not. It seems to be accepted practice.

Small studies on nutrients aren't likely to have ties to large corporate financial backers obviously because there obviously isn't a lot of profit for Big Pharma.... such as a special version of a vitamin that proves to be extremely effective for safely managing a defect in methylation.

My comments were focused on the actual results by doctors who rely on nutrients rather than drugs to remedy ailments and conditions safely and effectively without the side effects that typically accompany pharmaceutical drugs. When these doctors write about their successes, protocols and treatment plans, they'll include references for published study results as well detail fundamentals of nutritional biochemistry showing why and how a nutritional deficiency can manifest in an ailment, adverse health condition or allow for an outside influence or pathogen to overpower the host.

Of course, natural, doesn't mean safe... just like food crops... thought to be natural, but considering the dilemma of pesticide residues and GMO foods that permeate the farming industry today, "natural" food isn't what one might think it is.

Jackie

I have absolutely no time for or interest in debates about the FDA, conspiracy theories, Big Pharma, and all the other boogeymen of the alt-health world.

Let's all just remember that the supplements industry is a huge business with billions of dollars at stake. Anyone who thinks the people manufacturing and selling supplements, and the people writing books about supplements, and the people pushing supplement plans and programs aren't in it for the money is kidding themselves. They're in it for the money every bit as much as Big Bad Pharma, but unlike Big Bad Pharma they have virtually no oversight. They don't have to prove their supplements work. They don't have to prove they're safe. They don't even have to prove that the dosages are accurate or that they don't contain dangerous contaminants.

Skepticism is healthy and the supplements industry needs a huge dose of it. Personally, I think it should be regulated exactly the same as the prescription drug industry.