To Anti-Coag or Not To Anti-Coag

I've had afib since March, 2013 but wasn't diagnosed and made certain of it until my first cardiologist visit in 2018. I took no pharmaceutical medications in the intervening 5 years. On that first visit, the cardio did not prescribe any meds nor did I ask for any.

As my episode frequency was increasing despite using a host of alternative solutions, I asked my cardio for something pharmacological. He prescribed flecainide starting I think with 200 mg. a day. It seemed to help at first. We later increased to 300 mg a day.

Frequency of episodes continued to creep up, more to the point, my heartrate which previously had been under 120 on afib, started to increase to 130 or more in afib, with brief jumps to 140-160. So my doctor added metropolol at 50 mg. a day, which was fantastic for about 3 weeks–I felt great–then the episodes started to creep in again and now I'm on 100 mg of metropolol. My heartrate in afib is thankfully much lower with the metropolol.

I have an appointment to be ablated by Dr. Natale at the end of April (thanks Shannon!) It is mandatory before the operation to be on an anti-coagulent for 2 to 4 weeks. Dr. Natale's scheduling nurse told me that if one has afib episodes that are 6-8 hours or longer, they should be on a blood thinner anyway.

Sometimes I am aware of when I'm in an episode and sometimes I don't know, and sometimes I have them in my sleep so I'm not always aware of how long they go. I think a few are of the 6-8+ hour variety.

My CHA₂DS₂-VASc score is 0. I am taking lumbrokinase, fish oil, krill oil, and gingko biloba, etc.

Should I go on a NOAC now or wait until the beginning of April (when I'll have to take it for the operation?)



Thank you Shannon for having this forum and to everyone who contributes.



Edited 3 time(s). Last edit at 02/13/2019 07:10PM by DavidK.

I would start it now. Frankly, you've probably just been lucky so far. I wouldn't push my luck further.

If you do start Eliquis (or similar), you might want to discontinue the other supplements such as lumbrokinase and gingko. There's no need to "double down" on anticoagulation. In fact, it may increase risk.

Check this out:
[medicalxpress.com]

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Carey
I would start it now. Frankly, you've probably just been lucky so far. I wouldn't push my luck further.

Why do you say that if his CHADS-V is 0?

Naturally if Natale says you should be on AC then that's settled. But I wonder where the 6-8 hours cane from, and why bother with everyone recommending the use of the CHADS-V if we're going to ignore it? Not a challenge to anyone but the whole thing seems very unclear.

Even a CHADS-Vasc 0 is at risk of stroke if you're have active afib. The atria don't pump effectively during afib, so blood can become stagnant and clot, particularly in the left atrial appendage. That's where 90% of all afib-related clots form. If a clot forms, when the episode terminates and the atria begin pumping again, the clot gets pumped out and there's your stroke. Afib strokes tend to be the biggest, worst strokes of all. Being a CHADS 0 won't protect you unless you no longer experience afib.

Hello David - Good to see that your date with Dr. Natale is arriving soon. I agree with Wolfpak about stopping the natural thinners when you begin the Rx anticoagulant. You can still use small doses of the fish oil but the Lumbrokinase and Ginkgo should be stopped. You don't want to risk having bleeding problems.

I'll be watching for your news.

Best to you,
Jackie

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Carey
Even a CHADS-Vasc 0 is at risk of stroke if you're have active afib. The atria don't pump effectively during afib, so blood can become stagnant and clot, particularly in the left atrial appendage. That's where 90% of all afib-related clots form. If a clot forms, when the episode terminates and the atria begin pumping again, the clot gets pumped out and there's your stroke. Afib strokes tend to be the biggest, worst strokes of all. Being a CHADS 0 won't protect you unless you no longer experience afib.

I see that point. Then why do they even attach the CHADS-VASc score to AFib in the first place. Seems like anyone with AFib needs AC no matter what because any bout of AFib had the potential for stasis.

And really to confuse matters more everything I've ever read for AFib was to not recommend AC to those with CHADS-VASc 0.



Edited 1 time(s). Last edit at 02/14/2019 02:06PM by Brian_og.

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Brian_og
I see that point. Then why do they even attach the CHADS-VASc score to AFib in the first place. Seems like anyone with AFib needs AC no matter what because any bout of AFib had the potential for stasis.

And really to confuse matters more everything I've ever read for AFib was to not recommend AC to those with CHADS-VASc 0.

I'd say anyone in active afib needs anticoagulation no matter what, which means if you're persistent then your CHADS-Vasc score really is kind of irrelevant. But if you're paroxysmal and have your afib under control with drugs or an ablation, or if your episodes are rare and very short, then the score comes into play determining if you need an anticoagulant. For example, if you're a CHADS-Vasc 0 and you have a successful ablation, your EP will probably tell you that you can stop anticoagulants after the blanking period (mine did after my second ablation). But if you're a CHADS-Vasc 3 it's unlikely he'll ever okay stopping. Similarly, when my afib first began it would occur once or twice per year and last no more than six hours. My EP didn't think I needed an anticoagulant. If the episodes had lasted longer he would have.

My CHADS score = 0, but I've still afib one hour or two every week (sometimes even less than 1hr). I'm currently taking dabigatran, but I wonder if it's safe.
My docs say the risks are 50/50, so it's hard to decide, but my fear of a stroke is greater than that of bleeding.
My EP recently said that if I'm comfortable with my AC, it would be wise switching to the 110mg version.
What do you think I should do ?

Personally, I would probably stop it altogether, but if you're uncomfortable with that then I'd go with the low dose. It will still provide coverage but with a lower bleed risk.

I'd like to stop too, just because I dislike taking meds, but it's still about 5-6hr afib/month...
I've to speak with my cardiologist too.
Thanks for your help.



Edited 1 time(s). Last edit at 02/16/2019 12:41PM by Pompon.

It would be so nice to know what's the minimum time in AF to form a clot. The ASSERT trial came up with 24hrs I think but that applied to sub clinical and I don't know if that might even apply to PAF. Looks like Natale thinks 6-8 hours?

"It would be so nice to know what's the minimum time in AF to form a clot. The ASSERT trial came up with 24hrs I think but that applied to sub clinical and I don't know if that might even apply to PAF. Looks like Natale thinks 6-8 hours?"

I would guess that there are a lot of variables that may impact the chance of a stroke. I had afib for 5 years miss diagnosed as irregular heart beat because of mitral valve prolapse. Many episodes were for several hours and not on any anti-coag. Then diagnosed and on meds for 6 years, then a successful ablation. I guess I should be dead. My average length of episodes during the last 6 years was 10 hrs. and there were 192 total. The number and length of episodes before diagnose are unknown, and probable less than after diagnoses.



Edited 1 time(s). Last edit at 02/18/2019 09:13AM by Ken.

I had many many 8+ hour episodes for about 10 years prior to ever being diagnosed and on Eliquis, and had no events I am aware of. I suspect your LAA morphology and EF has a lot to do with whether or not there are clots that form.

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AB Page
I suspect your LAA morphology and EF has a lot to do with whether or not there are clots that form.

Sounds like an interesting point...

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AB Page
I had many many 8+ hour episodes for about 10 years prior to ever being diagnosed and on Eliquis, and had no events I am aware of. I suspect your LAA morphology and EF has a lot to do with whether or not there are clots that form.

As I recall the data showing clot formation after just a few hours of AF came from a more elderly cohort with greater comorbidities, but it certainly does prove the point that clot formation can occur quickly. The good news is that the DOACs also act very quickly so PIP approaches in younger folks, especially those in high-risk professions (firefighter, police officer), are perfectly reasonable options. That would never work with warfarin. It takes weeks to adjust that medication.

Once a clot is formed AOCs don't dissolve it your own body does that, so if you are on an AOC you shouldn't be getting a clot.

L

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AB Page
I had many many 8+ hour episodes for about 10 years prior to ever being diagnosed and on Eliquis, and had no events I am aware of. I suspect your LAA morphology and EF has a lot to do with whether or not there are clots that form.

And diet no doubt. A plant based or predominately whole food plant based diet would give one a better chance of delaying clot formation providing inflammation markers are low.
Cardiologist told me that clots can form in as short a time as 2 hrs in AF.