Warfarin vs NOACs before cardioversion?

I have just been reading one of the posts regarding blood thinners and the pros and cons of Warfarin and New Oral Anticoagulants (NOACs).

I am hoping to see the cardio doc at the local hospital in the next few days to discuss my recent re-acquaintance with none stop Atrial Flutter and I believe from experience that the only way to stop the AFL is via cardioversion i.e. the electrical shock treatment. Now before the hospital will do the cardioversion I will have to go on a course of warfarin that will take at least 3 weeks if all went perfectly i.e. I will have to have my blood checked every week and it must stay at a specific 'thinning' level for the full 3 weeks otherwise the tests start all over again. This is a very hit and miss affair as the last time I did this 10 years ago it took over 3 months to get 3 consecutive weeks where the 'thinning' levels were within the specific requirements.

My question is do the new NOACs make the whole blood 'thinning' procedure much more precise and thus ensuring there is much more chance of getting 3 consecutive weeks with acceptable blood thinning levels which allow the cardioversion to go ahead. Very frustrating knowing a successful cardioversion takes only minutes but can take weeks and sometimes months of taking warfarin/NOAC before the docs will go ahead with the procedure.

PS. After an unsuccessful ablation for AF in India I asked the EP why they hadn't tried to cardio convert me and he said I didn't think you wanted to try that. I said where's the machine I will race you or words to that effect. Unfortunately the two attempts they tried did not stop the AF but the question remains why would the guy agree to try without any 3 week course of warfarin if it so important. No complaints from me though.

Cheers,
Barry G.



Edited 1 time(s). Last edit at 06/17/2019 09:47AM by Barry G..

Yes, NOACs are often used the exact same way. As long as you're fully compliant with the med, it's every bit as effective as warfarin so there's no reason to spend weeks getting an INR stabilized.

The other alternative is to do a TEE prior to the cardioversion. Assuming no clots are found by the TEE, you can skip that whole three weeks of waiting and do a cardioversion immediately.

Incidentally, I was the same way with warfarin. It took weeks to get my INR stabilized with multiple dosage changes and repeat INRs. That was 2010, and Pradaxa was approved by the FDA later that year. My EP switched me to Pradaxa the day it became available and I haven't been near warfarin since.

Hi Carey,

Many thanks for your informative post, it will give me something to present to the local cardio Doc who I am hoping to see and convince that I require a cardioversion to get me out of Atrial Flutter sooner rather than later. Its almost two weeks since I attended the A&E with the new onset of AFL and still no call from the hospital for me to see a Cardio Doctor at the Hospital as expected so it looks like I will have to push it with them, or if no luck, I will see about getting a cardioversion done privately.

Very interesting that you advise that having a TEE done eliminates all the grief of the three weeks taking warfarin/NOACs trying to get the acceptable INR level and much as I hate the TEE procedure I think I would take that very quick route if given the option. The TEE option as you explained now clears up why the Hospital in India had no worries of trying a cardioversion on me has they had carried out a TEE only the day before.

Cheers,
Barry G.

Barry

I think Warfarin is very tricky. My Jan 2003 ablation should have happened in November 2002 but a TOE/TEE in the morning found a clot and I was turfed out of the hospital with supplies of calcyparin and instructions on what to do. I had been on Warfarin for over a year.

In the weeks leading up to the TOE I was totally focused on getting to Bordeaux. I used to insist on weekly blood tests rather than the monthly ones that the hospital usually did, and I adjusted the dose myself (with the approval of the AC nurse). For months I was able to stay in range much better than when I followed the hospital's dosage. However on one single blood test it dropped to 1.8 when it should have been between 2 and 3. There was still a clot! (At that time neither NOACs nor INR home testing were available.)

If I couldn’t make it work, with all the effort I put in, I wonder how many people are actually achieving the iNR that they are aiming for. I suspect that most of them are not.

Gill

Hi Gill, thanks for your post.

Well so much for warfarin if you had been on it for a year and they still found a blood clot.

I too had a few 1.8 warfarin readings so they started the whole 3 weeks procedure all over again making it over 3 months before I got the hospital to carry out the cardioversion. I say I got them to do the cardioversion because I finally got two weeks with INR between 2 and 3 but the 3rd week it was 1.9, I was fuming when they said I had failed. I said something along the lines of go and get the machine and I am going to lie on the floor and you zap me now no messing about. It worked though they did the cardioversion either right then or the day after, can't remember exactly what happed has the 'red mist' had come down ;-)

Cheers,
Barry G.