Stroke after cardioversion.

Interesting twitter conversation among some EP's regarding stroke after a cardioversion even though the patient was on Xarelto. Some seem to think that a TEE should always be done even if the patient is fully noac compliant.

One also refers to the fact that Pradaxa has a longer half life than Xarelto and might be a better choice.


[twitter.com]

Here, performing a TEE before an ECV seems being the norm.
I don't know if Pradaxa has a longer half life, since it's given 2 times a day. Here, people are more often prescribed Xarelto because of its convenience of just one small pill a day.
I've felt better with Pradaxa than with Xarelto or Lixiana, but the two big tabs to swallow each day and the awful packaging are no fun.

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Brian_og
Some seem to think that a TEE should always be done even if the patient is fully noac compliant.

Also, how does one truly know if a patient HAS been NOAC compliant? Especially if they - as is truth told the case to some degree for most of us - are becoming a bit forgetful as they get older? I've a few times found myself not remembering at midday whether I've had my a.m. dose of whatever!

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mwcf
Some seem to think that a TEE should always be done even if the patient is fully noac compliant.

Also, how does one truly know if a patient HAS been NOAC compliant? Especially if they - as is truth told the case to some degree for most of us - are becoming a bit forgetful as they get older? I've a few times found myself not remembering at midday whether I've had my a.m. dose of whatever!

My cell phone never forgets

With Xarelto you have to ask not only if they're compliant but also if they take it with food since Xarelto has to be taken with a meal to be fully absorbed.

Personally, I wouldn't take Xarelto. Taking one pill per day vs. two isn't much of a difference in my life, and I can't always guarantee I'll have a meal available when pill time rolls around. At least for me, having to take it with food wipes out the trivial convenience of only taking it once per day. It also has the shortest half-life of all the NOACs (11 hrs), so I don't quite get how it can be taken only once. Sounds to me like trading trivial convenience for lower effectiveness.

I had a stroke while taking Eliquis. The doctors assumed that my stroke was a result of a clot caused by a-fib because of my history. (3 ablations). I have a pacemaker....and when it was checked, it showed that I had been in normal sinus rhythm with NO a-fib for many weeks before the stroke, during the stroke, or after the stroke. So it appears that my stroke likely occurred from plaque that had formed in an artery somewhere. It is fortunate that I was taking Eliquis as the stroke could have been much more serious and i had a quick and good recovery. Sometimes people are advised by their physician to switch to a different anticoagulant thinking the anticoagulant they were previously taking might not have been effective......but I have remained on Eliquis. It has been 4 years since my last ablation and I have been in NSR since that time. I still continued to take Eliquis after the stroke... and will continue to do so. What was so surprising to me was that an anticoagulant is not a 100% guaranteed prevention against stroke....but it certainly can be important in the seriousness and the recovery process. I was switched from Pradaxa to Eliquis at one time after I had an intestinal bleed. I do not find taking 2 doses of Eliquis a day...with or without food...to be a problem to remember.
I'd had a cardiac cath procedure about a year and a half before my stroke and it did not show any blockage in my arteries....so the stroke was definitely an unexpected event for me.

There have been several people on this board that have gotten a stroke while taking an anticoagulant, that is only this board what about the general population? I know a couple of people that have had a stroke and they do not have AF, their stroke was minor as well.

L

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JustMeToo

So it appears that my stroke likely occurred from plaque that had formed in an artery somewhere.

I'd had a cardiac cath procedure about a year and a half before my stroke and it did not show any blockage in my arteries....so the stroke was definitely an unexpected event for me.

Did your doctor suggest that, or was the cause unknown?

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JustMeToo
What was so surprising to me was that an anticoagulant is not a 100% guaranteed prevention against stroke...

From the coumadin studies I've seen, it reduces stroke risk about 50%. The studies for the newer meds, that I'm aware of, are judged "non-inferior" to warfarin. Hence about the same risk reduction.

The 50% is from where a person starts. If they have a CHA₂DS₂-VASc score of 0 then it would halve that risk. If their score is 5, then it would halve that much greater risk. So a person with a high CHA₂DS₂-VASc score on OAC could end up with a significantly higher risk than someone with a low score who is not taking OAC. Hence it makes sense to lower any controllable variables in the CHA₂DS₂-VASc score in addition to taking the OAC. Stroke risk is never reduced to zero.

When they did my cardioversion back in early August they almost did not do a TEE. EP asked if I had been regular with my eliquis since my ablation in July. I said that I had been. Then a short time later he dicided to go ahead and do one just as a percaution.

My doctors suggested that the plaque was the likely cause...but the exact cause is still a mystery. My blood pressure was not an issue.

Several factors to consider... when in arrhythmia, blood can pool or stagnate in some areas esp. in the heart chambers.
That's where the anticoagulants help to keep afibbers stroke free. Prolonged afib increases the clotting tendency - thus reason for prescribing the OACs.

However, there are also other factors that need to be recognized as contributors even if on an anticoagulant.. and especially, if you're not.

I've not seen it reported that anticoagulants reduce or manage arterial inflammatory factors; but, rather, work on the various clotting pathways to make blood less likely to clot easily or quickly... yet still remain within a relative 'safe' range.

The risk of stroke encompasses the factors that contribute to an "environment" in arteries that are conducive to plaque formation and therefore, plaque rupture and also tendency to form clots. A major influencing factor would include inflammation which is measured by High Sensitivity C-reactive Protein. Since plaques can create a 'bottleneck' or even rupture , a loose piece causes blockage, that's another consideration for areas with existing plaques.

Long term warfarin use causes arterial and tissue calcifications so it is now recommended to use Vitamin K2 in the Menaquinone 7 form for that very reason but that adverse effect wasn't known for a number of years.

The practitioners of Functional Medicine recommend monitoring by various lab testing the factors that contribute to inflammation and other risk factors not managed by anticoagulants just to be sure the "environment" is healthy.

Here's a list of previous posts on this topic and the various lab tests... and why.

Silent Inflammation – Risk Marker for Stroke, Heart Attack & Much More
April 07, 2012
[www.afibbers.org]

Sticky, thick blood - risk of stroke or MI
September 06, 2012
[www.afibbers.org]

Clot risk
April 15, 2017
[www.afibbers.org]


Jackie

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Jackie

Long term warfarin use causes arterial and tissue calcifications so it is now recommended to use Vitamin K2 in the Menaquinone 7 form for that very reason but that adverse effect wasn't known for a number of years.

Only if you subscribe to the myth not to eat foods with vitamin K. The jurys out on the long term consequences of NOAC's, but the original post isn't about warfarin:

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Interesting twitter conversation among some EP's regarding stroke after a cardioversion even though the patient was on Xarelto.

Even at the low end of therapeutic range, INR 2.1, I know I'll be clot free. I've tested this out a number of times. I wonder what the effects of monthly bills of >$500 for one overpriced medication are. That might add to risk of stroke.



Edited 1 time(s). Last edit at 10/07/2018 11:21AM by jpeters.

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jpeters
Even at the low end of therapeutic range, INR 2.1, I know I'll be clot free. I've tested this out a number of times. I wonder what the effects of monthly bills of >$500 for one overpriced medication are. That might add to risk of stroke.

Um, no, you don't know that. You tested it? How would one go about "testing" it? And the NOACs are expensive but they don't cost over $500 per month.

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Carey

Even at the low end of therapeutic range, INR 2.1, I know I'll be clot free. I've tested this out a number of times. I wonder what the effects of monthly bills of >$500 for one overpriced medication are. That might add to risk of stroke.

Um, no, you don't know that. You tested it? How would one go about "testing" it? And the NOACs are expensive but they don't cost over $500 per month.

With TEE's. How much do you pay for it, maybe only $445.53?

An interesting way of looking at costs of noacs versus warfarin. Cheaper for the Healthcare system overall due to less strokes and less bleeding.


[www.ncbi.nlm.nih.gov]

[www.patientcareonline.com]

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Brian_og
An interesting way of looking at costs of noacs versus warfarin. Cheaper for the Healthcare system overall due to less strokes and less bleeding.


[www.ncbi.nlm.nih.gov]

[www.patientcareonline.com]

1. The study used different populations:

"A note of caution about the results: although event rates for the warfarin comparator arm were identified among a “real-world” patient population, the event rates in the NOAC arm were obtained from Phase III studies of highly selected patients."

2. There are many reasons people have strokes. The population that is taking warfarin may be different than those who can afford an NOAC. For example, vets use warfarin because the VA won't prescribe an NOAC.

3. 1.1 per 100 additional stroke risk would translate as major expense to the system. However, that's not a cost that paid by the average user. Compliance is a major factor that benefits the use of an NOAC. People that don't comply with taking their medications and maintaining a healthy diet in addition to complying with testing will get more strokes.



Edited 1 time(s). Last edit at 10/07/2018 04:03PM by jpeters.

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jpeters


Even at the low end of therapeutic range, INR 2.1, I know I'll be clot free. I've tested this out a number of times. I wonder what the effects of monthly bills of >$500 for one overpriced medication are. That might add to risk of stroke.

Um, no, you don't know that. You tested it? How would one go about "testing" it? And the NOACs are expensive but they don't cost over $500 per month.

With TEE's. How much do you pay for it, maybe only $445.53?

I pay approximately $88 dollars every 3 months for Eliquis with my Part D drug plan plus I do not have any lab fees monthly/ bimonthly. It’s just a overwhelming majority of EP’s, Cardiologist etc who believe the newer NOAC work better. I trust there judgment but completely understand individuals who cannot afford the Newer NOAC’s even if they have insurance. You will get in the Donut hole taking Eliquis,Xarelto etc.

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jpeters
With TEE's. How much do you pay for it, maybe only $445.53?

Obviously it's not practical to undergo TEEs routinely. Regardless, people on warfarin with their INR well within range still have strokes. None of the anticoagulants provide 100% protection.

I've paid nothing at all for Eliquis the last two years. My insurance carriers (Cigna in 2017, Aetna in 2018) consider NOACs preventative care and therefore cover them fully without deductible or copay. Prior to that, Eliquis and Pradaxa both cost me a $40 copay. If I had to pay for Eliquis entirely out of pocket I can get it for $122 per month.

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Carey

With TEE's. How much do you pay for it, maybe only $445.53?

Obviously it's not practical to undergo TEEs routinely. Regardless, people on warfarin with their INR well within range still have strokes. None of the anticoagulants provide 100% protection.

I've paid nothing at all for Eliquis the last two years. My insurance carriers (Cigna in 2017, Aetna in 2018) consider NOACs preventative care and therefore cover them fully without deductible or copay. Prior to that, Eliquis and Pradaxa both cost me a $40 copay. If I had to pay for Eliquis entirely out of pocket I can get it for $122 per month.

I'm guessing it's getting subsidized somewhere, given listed prices.
Thanks for the information that people on anticoagulants still have strokes.
(and that it's not practical to undergo TEEs routinely)

[www.drugs.com]



Edited 1 time(s). Last edit at 10/07/2018 07:00PM by jpeters.

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jpeters
I'm guessing it's getting subsidized somewhere, given listed prices.

No, you just need to know where to buy drugs that are ridiculously overpriced in the US because Congress refuses to control drug prices like every other country on earth does. I recommend https://www.planetdrugsdirect.com

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Carey

I'm guessing it's getting subsidized somewhere, given listed prices.

No, you just need to know where to buy drugs that are ridiculously overpriced in the US because Congress refuses to control drug prices like every other country on earth does. I recommend [www.planetdrugsdirect.com]

Never had to. Just picked up 3 month supplies of Coreg and Warfarin for $9.04.

Good idea, though, for pricey meds. How much is shipping?

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jpeters
Good idea, though, for pricey meds. How much is shipping?

Shipping is free. There's also a 5% discount if you pay by bank check.

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Carey

Good idea, though, for pricey meds. How much is shipping?

Shipping is free. There's also a 5% discount if you pay by bank check.

Can't beat that...Great for people without insurance.

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Carey

Good idea, though, for pricey meds. How much is shipping?

Shipping is free. There's also a 5% discount if you pay by bank check.[/quote

👍 Just gotta be smart. 100% agree with Carey. Also, Is it true that Coumadin is a form of Rat poison that was formerly used to kill Rats? Just asking......,

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smackman


👍 Just gotta be smart. 100% agree with Carey. Also, Is it true that Coumadin is a form of Rat poison that was formerly used to kill Rats? Just asking......,

Yes, sweet clover. If you're a rat, better stick with Eliquis.

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smackman
Also, Is it true that Coumadin is a form of Rat poison that was formerly used to kill Rats? Just asking......,

No, it’s currently used to kill rats. It was discovered serendipitously in the 1930‘s when mass cattle die-off was traced to tainted feed. All the cows died of internal hemorrhage. So veterinarians figured out what was causing it and isolated the compound. Once they had that, it wasn’t rocket science to figure out how to OD the rats.

Okay, It’s time to move on. This discussion is simply a choice for most AFIB patients. For me and my EP and local Cardiologist, I will stay with Eliquis or one of the newer NOAC’s.

If someone cannot afford this option or just feels Coumadin is a better option, take it and all the labs that come with it.

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smackman
Okay, It’s time to move on. This discussion is simply a choice for most AFIB patients. For me and my EP and local Cardiologist, I will stay with Eliquis or one of the newer NOAC’s.

If someone cannot afford this option or just feels Coumadin is a better option, take it and all the labs that come with it.

The discussion was about strokes after cardioversion even though the patient was on Xarelto.

Just had my INR test. Same place it was 8 weeks ago, and 8 weeks prior to that. For some, it's a big deal.

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jpeters
The discussion was about strokes after cardioversion even though the patient was on Xarelto.

Just had my INR test. Same place it was 8 weeks ago, and 8 weeks prior to that. For some, it's a big deal.

What's? a big deal? People have had strokes following cardioversion despite being on warfarin too. The NOACs work as well as warfarin, have lower bleed risk, fewer side effects and drug interactions, and don't require testing. Warfarin is cheaper. It's a choice, like Smackman said. I don't see a big deal.

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Carey

The discussion was about strokes after cardioversion even though the patient was on Xarelto.

Just had my INR test. Same place it was 8 weeks ago, and 8 weeks prior to that. For some, it's a big deal.

What's? a big deal? People have had strokes following cardioversion despite being on warfarin too. The NOACs work as well as warfarin, have lower bleed risk, fewer side effects and drug interactions, and don't require testing. Warfarin is cheaper. It's a choice, like Smackman said. I don't see a big deal.

Carey, you just can't drop this, can you? I was responding to Smackman's comment about "all the drug tests that come with it." FWIW, coumadin is a relatively safe, but highly effective, drug. Long term users (longer than one year) have had substantially lower bleed (major and minor) events than short term users ( >50%). Your comment about fewer side effects I'll leave along...People can read user comments all over the internet. Personally, I don't trust them. Warfarin is a plant. Enough said.....

jpeters…From your research, do you know if the plant source for warfarin/Coumadin is the same plant,
Murraya paniculata, that has been used experimentally in the study of cancer metastatic chemo-preventive materials?


Thanks.
Jackie



PS – for those using warfarin, Hans Larsen’s early report on Living with Warfarin has a list of Interactions that potentiate and inhibit warfarin’s effects… on page 11… [www.afibbers.org] - 86 references.

I'm not so sure it's me who won't drop it. I wasn't referring to anecdotal reports on the internet. Warfarin has far more drug interactions and side effects than the NOACs. That's just fact. Feel free to compare them side by side on drugs.com, rxlist.com, or the pharmacology site of your choice.

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Jackie
jpeters…From your research, do you know if the plant source for warfarin/Coumadin is the same plant,
Murraya paniculata, that has been used experimentally in the study of cancer metastatic chemo-preventive materials?

Don't think so, since "Murraya paniculata is a tropical, evergreen plant native to Southeast Asia and China."
Warfarin comes from sweet clover, and (it's effects on animals) first noticed in the northern US and Canada in 1920.

"Through degradation experiments they established that the anticoagulant was 3,3'-methylenebis-(4-hydroxycoumarin), which they later named dicoumarol. They confirmed their results by synthesizing dicoumarol and proving in 1940 that it was identical to the naturally occurring agent."


"Specifically, studies in cancer models have shown that warfarin blocks AXL receptor tyrosine kinase by inhibiting a vitamin K-dependent protein called Gas6, which may halt the spread of cancer cells."


Carey, I'm bored

Wikipedia/wiki/Warfarin

"Warfarin" is on the World Health Organization's List of Essential Medicines, the most effective and safe medicines needed in a health system."

Warfarin" is on the World Health Organization's List of Essential Medicines, the most effective and safe medicines needed in a health system."

Wasn't safe for me, I got bloodshot eyes and when just exerting a little pressure upon opening a door, my thumb had a sack of blood. After quitting Coumadin two weeks later I got a nose bleed and coughed up some blood clots. Glad it works for you.

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Elizabeth


Wasn't safe for me, I got bloodshot eyes and when just exerting a little pressure upon opening a door, my thumb had a sack of blood. After quitting Coumadin two weeks later I got a nose bleed and coughed up some blood clots. Glad it works for you.

Yeah, I remember you posting this before. Were you on long enough to get an initial INR? Either something unique with your metabolism, or overdose, not sure which. You can safely have surgery being off Coumadin for 3 days, so don't understand the nose two bleed weeks later. An anticoagulant doesn't cause bleeding, just increases clotting time.



Edited 1 time(s). Last edit at 10/10/2018 12:09AM by jpeters.

Folks, this anecdotal warfarin vs. NOACs stuff is useless. Some drugs work for some people and they don't work for others. Warfarin is a perfectly reasonable choice if it works for you. NOACs are a completely reasonable choice if one of them works for you. I've tried to supply the facts on what the pros and cons are for both of them based on clinical studies involving thousands of people. Your results may differ, but that doesn't change the results for *most* people.

Jpeters said;
Yeah, I remember you posting this before. Were you on long enough to get an initial INR? Either something unique with your metabolism, or overdose, not sure which. You can safely have surgery being off Coumadin for 3 days, so don't understand the nose two bleed weeks later. An anticoagulant doesn't cause bleeding, just increases clotting time.]

Yes, I was on it for about a month, I did get an INR, I do have low platelets. I don't know why it happened a couple of weeks later but it did.

It is said on here that an anticoagulant doesn't cause bleeding, I just can't understand that statement because it happens all the time.

What are the potential side effects of anticoagulants?

The two most serious side effects of anticoagulants are bleeding and gangrene (necrosis) of the skin. Bleeding can occur in any organ or tissue. Bleeding in the kidneys can cause severe back pain and blood in the urine. Bleeding in the stomach can cause weakness, fainting, black stools, or vomiting of blood. Bleeding of the brain can cause severe headache and paralysis, and bleeding of the joints can cause joint pain and swelling.



Edited 1 time(s). Last edit at 10/10/2018 01:28AM by Elizabeth.

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Elizabeth


It is said on here that an anticoagulant doesn't cause bleeding, I just can't understand that statement because it happens all the time.

You're right. More rare than just slowing clotting, but can happen. I stand corrected on that one.

" When you don't have enough platelets in your blood, your body can't form clots. A low platelet count may also be called thrombocytopenia "

[www.healthline.com]



Edited 2 time(s). Last edit at 10/10/2018 09:37AM by jpeters.

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Carey
Folks, this anecdotal warfarin vs. NOACs stuff is useless. Some drugs work for some people and they don't work for others. Warfarin is a perfectly reasonable choice if it works for you. NOACs are a completely reasonable choice if one of them works for you. I've tried to supply the facts on what the pros and cons are for both of them based on clinical studies involving thousands of people. Your results may differ, but that doesn't change the results for *most* people.

Results of broad based studies that combine diverse groups looking at one or two variables don't necessarily apply to ANY individual people. Calling the results "facts" to dismiss actual experiences as "anecdotal" is a problem for people who don't understand studies.



Edited 1 time(s). Last edit at 10/10/2018 12:34PM by jpeters.

My platelet count is at the very low end or a couple of numbers below the lab scales so not as low as that article is talking about. Doctors have never been concerned, but could cause problems if taking anticoagulants.

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jpeters
Results of broad based studies that combine diverse groups looking at one or two variables don't necessarily apply to ANY individual people. Calling the results "facts" to dismiss actual experiences as "anecdotal" is a problem for people who don't understand studies.

As a non-indidividual person unsure as to whether or not I belong to any diverse groups I must admit that I don’t understand how to satisfactorily differentiate the facts from anecdotal experiences...........



Edited 6 time(s). Last edit at 10/10/2018 03:02PM by mwcf.

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jpeters
Results of broad based studies that combine diverse groups looking at one or two variables don't necessarily apply to ANY individual people. Calling the results "facts" to dismiss actual experiences as "anecdotal" is a problem for people who don't understand studies.

Sigh.... This is getting ridiculous. Reports of individual experiences are anecdotal by definition. In evidence-based medicine the facts you dismiss are arrived at through broad based studies. That's how science works. But yes, those results don't necessarily apply to any particular individual. I never said they did. I said they apply to most people and that is true.

Some levity, if y'all will.



Edited 1 time(s). Last edit at 10/10/2018 04:59PM by AB Page.

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AB Page
[i.kym-cdn.com]

Some levity, if y'all will.

LOL... Thanks!

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Elizabeth
My platelet count is at the very low end or a couple of numbers below the lab scales so not as low as that article is talking about. Doctors have never been concerned, but could cause problems if taking anticoagulants.

Apparently thrombocytopenia can be triggered by other medications besides anticoagulents.

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Carey

I said they apply to most people and that is true.

Won't help if I die of a stroke that an NOAC didn't remove.

Problem is myriad circumstances and what my question is, If I want to measure length of time to remove an existing clot , for example, important variables might be paroxysmal vs persistent, length of time prior to diagnosis, size and density of clot, normal or weakened ejection function, etc, etc. Good luck setting up the study. On an individual basis, it was quite easy with regular TEE's to measure the clot first on Eliquis and then on warfarin.

On any study involving warfarin, it would be essential to look at variables within the warfarin group such as level of compliance, INR levels (stabilized?), diet (inclusion of leafy vegetables, etc), etc. Again, good luck.



Edited 2 time(s). Last edit at 10/11/2018 11:28AM by jpeters.

Taking two a day is now simple...in the past I could forget the second one. Now I have two small neon coloured containers which I keep om my benchtop near my jug with my morning and afternoon pills.


I also have a selfie of myself in the throes of an AF episode on my fridge door, at eye level, with a little comment on it... TAKE YOUR MEDICINE. Silly and it annoys me but it reminds me as well!