Recommendations for Antithrombotic Therapy in Atrial Fibrillation

ACC/AHA/ESC Recommendations for Antithrombotic Therapy in Atrial Fibrillation Based on Underlying Risk Factors


Patient Characteristics Antithrombotic Therapy

Age < 60 yr, no heart disease (lone atrial fibrillation) Aspirin, 325 mg daily, or no therapy

Age < 60 yr, heart disease but no risk factors Aspirin, 325 mg daily

Age >/= 60 yr but no risk factors Aspirin, 325 mg daily

Age >/= 60 yr with DM or CAD Warfarin (INR, 2.0-3.0); consider addition of

aspirin, 81-162 mg daily

Age >/= 75 yr, especially in women Warfarin (INR, 2.0)
Heart failure Warfarin (INR, 2.0)

LVEF </= 0.35 Warfarin (INR, 2.0-3.0)

Thyrotoxicosis Warfarin (INR, 2.0-3.0)

Hypertension Warfarin (INR, 2.0-3.0)

Rheumatic heart disease (mitral stenosis) Warfarin (INR, 2.5-3.5 or possibly higher)

Prosthetic heart valves Warfarin (INR, 2.5-3.5 or possibly higher)

Prior thromboembolism Warfarin (INR, 2.5-3.5 or possibly higher)

Persistent atrial thrombus on TEE Warfarin (INR, 2.5-3.5 or possibly higher)

ACC/AHA/ESC-American College of Cardiology/American Heart Association/European Society of Cardiology
CAD-coronary artery disease
DM-diabetes mellitus
INR-international normalized ratio
LVEF-left ventricular ejection fraction
TEE-transesophageal echocardiography

Thank you Theo
That's exactly what I was looking for to take to my Dr appt on Friday.
Just in time.

Elaine

Hans,

How does this compare to your findings?

Carol

Carol,

These recommendations are the current accepted standards and I have no problem with them if you wish to use drugs in your stroke prevention program.

Hans

Some of the pieces of this puzzle don't seem to fit together.

For a person under age 60 with no heart disease and lone atrial fibrillation, the American College of Cardiology recommends either 325 mg of aspiran daily, OR NO THERAPY (take your pick).

Let's assume that I am age 58, have no heart disease, have lone atrial fibrillation, and the fibrillation is paroxysmal. While in fibrillation, I do not have a dangerous heartrate. Let's further assume that I have maybe three episodes a month on average. These episodes last for different lengths of time, but they always spontaneously end and I revert to normal sinus rhythm (NSR) automatically (with no help from drugs, doctors, emergency rooms, etc.). For some unknown reason all of a sudden I notice that I am back in NSR (I am a happy man). I opt for the NO THERAPY recommendation of these kings of cardiology. I am not taking coumadin. I am not taking aspiran. I am not taking anything. I just go about my life and sometimes I am in afib and sometimes I am in NSR. I don't worry when in afib because hundreds of times before I automatically have popped out of afib and back into NSR, and why should this time be any different. Let's assume some of my episodes last for only a few hours, some last for a day, and occasionally I have an episode that lasts a week. NO WORRY, because the cardiology experts have said that if I am 58 and have no heart disease and have lone atrial fibrillation I don't need any therapy. Period. They don't have a bunch of asterisks, disclaimers, and CYA language. They simply state I don't need any therapy, and since they say that, they obviously are not worried about me being at higher stroke risk than the general population of 58 year olds. Even if I have been in afib for a week (many days past the magic 48 hour period), they seem to have no worries about stroke risk when I spontaneously convert back to NSR. So I say O.K. Good deal. I won't take anything and I won't worry.

In the real world of cardiology, however, there seems to be a 48 hour rule. Almost any cardiologist will tell me that before I reach 48 hours in afib, I need to go to an emergency room and get cardioverted. And God forbid that I go to that ER three days after I went into afib. They will tell me that they can't cardiovert me and that I should have come in two days ago and that I will need to go on coumadin for two weeks and then they will cardiovert me. I believe what I have stated in this paragraph is what most cardiologists and ER doctors do in the real world. This contradicts and ignores what the American College of Cardiology preaches. Am I wrong?

If it is O.K. to take no therapy, then there should be no worry about the length of time I have been in fibrillation in case I automatically pop back into NSR. There should also be no reason to have some medical person convert me, either electrically or by drugs.

To conclude, if I am less than 60 and have no heart disease and have lone atrial fibrillation and am taking no therapy (no aspiran and no coumadin), and do not have a dangerous heartrate, then I can forget about and completely disregard the 48 hour rule, and my cardiologist and the ER doctors should do the same, and also there is no reason to be cardioconverted, and also if I do want to be cardioverted for some reason, I do not need to delay for days of blood thinning action. Just zap me now Doc!

I believe the last paragraph above is exactly the way afib should be treated according to the ACC guidelines. However, I also believe that the vast majority of cardiologists would not treat their patients according to that paragraph. If this is true, do the cardiologists not understand the guidelines and their implications?

The way I read all of this, if you are under age 60 and have no heart disease and have lone atrial fibrillation and do not have a dangerous heartrate while in afib, you should just relax. Do not worry about the 48 hour rule. Do not go to the emergency room. Do not get cardioverted. Do not go on coumadin. Do tell any physician that advises you to do any of the above that it is time for the two of you to have a long talk.

Am I correct in my analysis? Comments?

Newman

Hello Newman. Those are cogent observations. Something similar has been moiling around in my own head while considering what best to do for my own safety.

I am 61 and have no risk factors except my blood pressure, which is controlled by lisinopril at around < 120/70.

I don't know whether that is still considered a risk factor. Back when i still had health insurance the doctor i had then was conflicted about whether i should be taking coumadin, and i didn't want to, and she didn't insist. At that time she did know i was taking aspirin for arthritis. I still do, except for times when my knees hurt so badly that aspirin is not sufficient and i switch to naproxen. Its a bad idea to take the 2 together, and i don't.

Also i take fishoil, garlic, vit. E, and magnesium, all of which have anticoagulant properties.

I have done my best to cover all the bases i can, and only time will tell whether these measures are sufficient. Recently i have had a 'cluster' of short, mild afib episodes which converted back to nsr, the longest one lasting i think less than 10 hours. I didn't go to the emergency room or even call my health clinic. If i go to the emergency room there will be a large charge. I don't want it. Neither do i want to deal with ER procedures which are more aversive to me than the afib at this point. I am very tired of explaining to overloaded emergency personnel why i think i am having an episode of afib.

Lots of people live to be old with afib, and i think strokes are not the norm. I have heard it said that good luck is a matter of being prepared, and i have done all i can. I will take what counsel i can get from friends here, hope for the best, and live my life the best way i know.

Any comment or suggestions are welcome.

Peggy

Newman and Peggy,

Mind you, I know flutter is less likely to cause clots, than AF, but I was out of rhythm for 1.5mths, and converted using flecainide. I was in NSR for 2.5 days, when I decided to call my doctor. They said I needed to immediately get to the hospital because I was at risk of a stroke. It scared me enough to oblige, and so I had to do heparin shots for a week and coumadin for about a month. I quit on my own. If there was a clot, of which I'll never know, then why didn't it rear its ugly head in the 2.5 days, prior to the hospital visit? I was on aspirin during the time of flutter, so I believe it was enough.

Richard

Newman,

I agree that there is a discrepancy here but have a few comments that might explain it:

80-90% of the patients with afib seen by your average cardiologist also has an underlying heart problem so there is a pronounced tendency to treat all afibbers as if they had a structural heart problem. Atrial fibrillation connected with heart disease is by nature adrenergic so this would explain why many vagal afibbers are started out on beta-blockers even though they most certainly should not be. Anyway, if you have an underlying heart problem or some other risk factor you are definitely at higher risk for stroke and the 48 hour rule would apply for sure - it gets a little more murky when you look at lone atrial fibrillation. There is a growing realization that it is not afib as such that increase stroke risk, but rather afib combined with other risk factors. Numerous studies have shown that without the risk factors an afibber is of no greater risk for stroke than is the average person without afib.

The official guidelines are based on large epidemiological studies and clinical trials. I doubt very much if the investigators split lone afibbers into those with short episodes and those with long episodes when they arrived at the guidelines.

Anyway, with the now proven efficacy of the on-demand approach it should no longer be necessary to worry about having episodes lasting 48 hours or longer.

Hans

Newman

Your above scenario (apart from the age) was how I lived with AF for 20 years. For the first 9 years of paroxysmal AF I went in and out of AF almost as you descibed. Dr's never caught it and said I was having palps and to unstress!! No antigoagulation. When it was diagnosed I was given digoxin for ten years - no anticoagulation. When new cardio discovered I was on digoxin he freaked and put me on antiarrhythmics. I had started to educate myself at this time and asked about anticogulation and was told emphatically NO. They said I had no risk and did not even need to take aspirin. Cardiodiversion was not an option for me either. I was never once asked to go to ER to get converted. When I asked why it was never given to me as an option I was told my AF was too long standing and it would not work. LIVE WITH IT I was told. So I told them i couldn't and asked for abaltion. Absolute NO was the answer. I was told I was far too young and healthy (I was 40 then). Take more sotalol. I had to live with this alone, with no understanding from anyone. I felt like everyone thought I was neurotic when I tried to tell them, so I diagnosed my self with panic attacks


The rest of my story is well documented on this board and how I got rid of it through diet alone. Today I am glad I never had a stroke but am also glad that all the fear factors of AF and stroke were not available to me.
Today I know the importance of keeping the blood thin and do it through diet. When I had AF my blood was as thick as treacle and blood tests for Drs' and me were a nightmare. The blood just would not come back. Maybe I had a lucky escape. I don't know.......

Fran

Newman - You describe exactly how I lived much of my 8 years prior to ablation. It wasn't until I developed a-flutter and went 4 days and then to the ER that they really got excited about no Coumadin. Now mind you, I had ridden out some very intense events with lots of frequency as well.
However, once I became 65 - I'm 67 now - The pressure was really on about Coumadin. That made no sense to me at all. But...as you say, once you show up after going beyond that 48 hour mark...boy, you are in trouble. I ended up with the TEE and cardioversion... no shots in the stomach, just waited on the coumadin levels to reach acceptable levels so in all, I was in afib 7 days total before the conversion. Talk about expensive!

I personally think it is 100% the CYA policy and I totally understand why.

Jackie

Hans - you are absolutely correct about vagal fibbers getting the beta blockers as a standard of care - initially.... I was on beta blockers for the first 5 years and had terrible control of the events.... hmmmm. wonder why? Even after I went to the Cleveland Clinic, beta blockers were still the drug of choice; and even now post-ablation, they were still trying to put me on a rate control BB along with the antiarrhythmic.

You should know, too, that with at least the cardiologists I've had at the CCF, they were not into the on-demand approach, which seems totally ridiculous to me.

Your point is a good one about the other risk factors becoming more important as age increases. That fact needs to be kept in mind at all times. The fact that diabetes is becoming so rampant, gives even more importance to the risk factor issue wrt strokes.

Jackie

Jackie,

Beta-blockers may actually be OK in the first month after ablation. After all, the heart has been exposed to some trauma, so any episodes might be more likely to be adrenergic in nature.

It is indeed unfortunate that physicians tend to rely more on drug salesmen than on medical journals for the latest research findings. The on-demand approach is continuing to gain acceptance. The latest article on the subject that I have read concluded:

"This is the first study to demonstrate the reproducibility of an oral propafenone loading dose in converting paroxysmal atrial fibrillation in patients without significant cardiac disease or hypertension. This finding may support the development of the "pill-in-the-pocket" treatment strategy in this group of patients."

Interestingly enough, these researchers used 450 mg of propafenone in people weighing less than 70 kg and 600 mg for those weighing more. This seems like a fairly high dose, so if this is safe then 300 mg should presumably be even safer.

Hans