higher risk of developing large blood clots

Since I am now in permanent AF I feel doomed to a stroke:

Stroke neurologist Dr Andrew Lee says a patient with an irregular heart beat has a higher risk of developing large blood clots which are "more likely to be fatal because of the size of the clot itself".

Audio interview included:
[www.abc.net.au]

Stephen L

I actually think Dr. Lee is lobbying for BI to get Pradaxa accepted in Australia:

From: [www.abc.net.au]

Australians at risk of stroke are concerned by federal government delays in putting a new anti-clotting drug Pradaxa on the Pharmaceutical Benefits Scheme.

Neverthless scary quote: "more likely to be fatal because of the size of the clot itself".

Sorry if I wasted any readers time.

Stephen L

How many people die from strokes specifically where clotting is the culprit? Not very many, when compared to heart attacks, cancer, organ failure and accidental deaths (often caused by health care professionals) - . So even if one had twice the risk of a clot-caused stroke, it doesn't seem likely that a stroke will be what kills you. I don't know anyone who died from a massive stroke - but I've had a bunch of friends and relatives die from various kinds of cancers.

Stephen:

My mother was in permanent AF for about 15 years, she died at 92, no stroke, died peacefully in her sleep from heart failure. When I was in Florida a few years ago I met a man who at that time was in his 80s, he said that he was in permanent AF for most of his adult life, it didn't stop him from doing everything he wanted to do. I have a brother and his wife that each had a small stroke within a year of one another, neither has AF.

Liz

I thought that the higher risk is when someone is going in and out of AF-NSR-AF-NSR and so on. In other words paroxysmal AF with frequent episodes.

Everything I've understood has said the greatest danger is the moment of conversion dislodging a clot due to the restored ejection fraction (correct term?), which would mean that if you're in permanent AF, that clot will just sit there in your atrium doing no harm.

Obviously, we need a refresher course on the basics. It's been awhile since some of the basics have even been talked about.

lisa
__________________________

So much of medicine is looking solely down the wrong end of the gun barrel, and that is really a pity for all of us---Shannon

I'm in permanent afib and have been for almost 2 years. I actually prefer it over going in and out of afib. No more anxiety. My heart is just doing its own thing. I take natto, Coq10, omega 3's, vitamin E, garlic, vitamin C etc. I am able to do most of what I usually have done - if I overdo it I get a bit of ache in my chest - so I slow down. I don't want to take any rat poison and will not. I simply believe that when its your time its your time. I'm seventy one in a month and I do what I can with natural things. To each his own I guess!

From what I have learned here and elsewhere an Af stroke is especially debilitating. In my opinion one would be better off dead than suffer an Af stroke.

Hey, Liz.

My mom had nearly the same experience as yours: long-term AF, died in her sleep at 92.

Dr. Lee's comment seems to me be out a little bit "out there."

/L

RE: Obviously, we need a refresher course on the basics

FROM: [www.uptodate.com]

INTRODUCTION — Embolization of atrial thrombi can occur with any form (ie, paroxysmal, persistent, or permanent) of atrial fibrillation (AF).

This line ruined my day: Its under: Prevention approach by CHADS2 score

Patient preference is an important issue, since the absolute reduction in stroke risk is likely to be small, but stroke remains a feared outcome.

Stephen

Stroke risk related to AFIB is almost entirely related to thrombus clot formation in the LAA that then gets embolized and travels .. either to the brain most commonly or as a Pulmonary embolism.

Such a clot in the LAA can become embolic after conversion from AFIB/Flutter to NSR or a jolt from an ECV or even a hard fall or thump on the chest and even from spontaneous dislodgement over time.

People in persistent AFIB are often victims of embolic strokes from the LAA even though they haven't gone through a conversion back to NSR in years, though that conversion to NSR is a prime culprit in triggering the embolic break away of said clot.

In other words, its a major risk factor with a very high likelihood of a bad outcome to walk around with a known clot in your LAA. Normally getting your INR high enough will dissolve most of those clots, but its much better yet to not have one to begin with.

My father who had AFIB drop dead of a massive stroke in 1986 at age 69. .. My sister who has persistent AFIB also had a stroke though lived, though is disabled even while on Coumadin.... In short, deadly serious strokes very much DO happen to people with uncontrolled AFIB.Flutter who still have an LAA to deal with, and in some cases even with a therapeutic INR level as well.

Recent studies including a very timely new article from the June 2013 issue of 'Heart Rhythm' the journal of the Heart Rhythm Society called: 'Anatomical characteristics of the Left Atrial Appendage in Cardiogenic Stroke with low CHADS2 scores' .

This article continues on from the seminal study by Di Biase with Natale's group in Austin and San Fran who first defined the stroke risks found in four morphological LAA shapes listed in progressive increase in stroke risk as: Chicken Wing ( lowest risk), Windsock, Cactus and Cauliflower ( greatest risk).

Cactus and Cauliflower are the LAA shapes with the greatest risk and both the article by Natales group as well as this new one by a Japanese group strongly argue for doing 3D CT scans to define the actual LAA morphology as the most important step in assigning either aspirin, NOACs, Vitamin K antagonist like Coumadin/Warfarin or going for an LAA ligation/occlusion procedure in order to offer the best protection against stroke and not rely only on CHADS2 scores or even CHADS2-VASc scores alone.

A person with CHADS2 score of 1 might get by with only aspirin or nothing while a CHADS2 =0 for that person you would give nothing at all.

Whereas a person with a Cauliflower and a CHADS2 score of 2 or greater should get full Vitamin K antagonist and also be considered for a Lariat or Watchman device up front due to the significantly added risk factors.

In other words we are about to get in the coming years a more fine tuned model for AFIB/LAA related stroke risk assignment and hopefully better recommendations for those who need nothing all the way up to better defining those .. like myself ... who should not mess around and just get rid of the LAA altogether.

Shannon

Shannon - I didn't know about your father or your sister's history - no wonder you wanted to get your situation take care of! So sorry to hear this, but glad you made the choice you did and you are doing so well.

Just to clarify..are you saying that people with intermittnet Afib have a high chance of a stroke too? I was under the impression that that wasn't a big concern unless you were in Afib for at least 24-48 hours, no?

Barb

Barb,
I was in and out of Afib last labor Day weekend for about 4 days and boom stroke on September 5.
Natale told me the shape of your LAA is an independent factor regardless of Chads scores.
Low Chads scores does not mean you wont stroke out as I find out the hard way.

Shannon,

Excellent and very important information!

Thanks!

George

Stephen - Don't forget that if your body has the tendency to produce thick, sticky blood typically from a large amount of oxidative stress and inflammatory factors which include diet, then that is always in play behind the scenes. The clotting problem arises because those underlying factors are not routinely addressed by the special tests beyond INR or Pro times. You have to ask or insist on having them. Every afibber should know the results of those tests... which were recently listed in the post by Iatrogenia when she found the link to the Red Flags post on those important markers.

Jackie

Dennis,

Your chances of suffering an ischemic stroke associated with lone atrial fibrillation is very low indeed unless you have other conditions that increase stroke risk such as hypertension, heart disease, diabetes, etc. Perhaps the following excerpt from the March 2012 issue of The AFIB Report will help put your mind at ease concerning your risk of stroke.

Long-term prognosis for lone afibbers
BELGRADE, SERBIA. In June 2007 cardiologists at the Mayo Clinic reported the results of a study carried out to determine the long-term prognosis of 76 patients with lone atrial fibrillation (AF). After an average follow-up of 30 years, 29% of paroxysmal and persistent afibbers had progressed to permanent AF. In most cases the progression to permanent AF occurred within the first 15 years after diagnosis. Survival in the study group at 92% at 15 years and 68% at 30 years was similar to or even slightly better than expected for an age- and sex-matched group of Minnesotans (86% and 57% at 15 and 30 years respectively). The development of congestive heart failure (19% of the group at 30 years follow-up) was not significantly higher than expected (15%).

During the follow-up, 5 strokes (0.2%/person-year) and 12 transient ischemic attacks (0.5%/person-year) occurred in the group – mostly among permanent afibbers. All strokes and TIAs (transient ischemic attacks) occurred in participants who had developed one or more risk factors for stroke during follow-up (hypertension in 12 patients, heart failure in 4, and diabetes in 3). Not a single stroke or TIA occurred among lone afibbers with no risk factors for stroke. This prompted the remark from the researchers – Our long-term data suggest that the increased risk of stroke in atrial fibrillation is due to “the company it keeps”. In other words, lone AF as such is not a risk factor for ischemic stroke. The overall conclusion of the study is highly reassuring to lone afibbers – After >30 years of follow-up of our rigorously defined cohort, findings confirm that overall survival is not affected adversely by lone atrial fibrillation.[1]

A group of Serbian cardiologists now report on a larger long-term study involving 346 patients with newly diagnosed lone atrial fibrillation (LAF). Their definition of LAF was AF in patients 60 years old or younger with no hypertension, underlying heart disease or other comorbid conditions that could explain the presence of AF. The average age of the study participants at baseline was 43 years (range of 18 to 60 years), 76% were male, and 12% had asymptomatic AF. The majority (70%) had paroxysmal (intermittent) AF at baseline with 22% having persistent and the remaining 8% having permanent AF. Permanent afibbers were significantly more likely to have an enlarged left atrium and asymptomatic AF when compared to paroxysmal afibbers. During the average 12-year follow-up, 35% of the group developed heart disease, 25% hypertension, and 10% diabetes.

During follow-up, 27% of paroxysmal afibbers and 55% of originally persistent afibbers progressed to permanent AF. The average time to progression was 10 years and the average age at which progression was documented was 55 years (range of 24 to 74 years). Older age at diagnosis and development of congestive heart failure were predictors of progression. Somewhat surprisingly, the development of hypertension was associated with a 30% decrease in the risk of progression from paroxysmal to persistent or permanent AF. It is likely that this is due to the fact that therapy with angiotensin II converting enzyme inhibitors was much more common among patients with hypertension (77%) than among those who retained normal blood pressure (5%). NOTE: Hypertension was defined as a blood pressure reading above 140/85 mm on 3 separate occasions.

A newly developed risk score, the so-called HATCH score (1 point each for hypertension, age of 75 years or older, and chronic obstructive pulmonary disease and 2 points each for heart failure and prior stroke or TIA) was found to accurately predict the risk of progressing from paroxysmal to permanent AF. A score of 0 was associated with a 20% risk of progression, a score of 1 with a 36% risk, and a score of 2 with a 63% risk of progressing to permanent AF.

Thromboembolism was documented in 14 patients (4%) over the 12-year follow-up period. Nine of the 14 patients suffered an ischemic stroke corresponding to an annual stroke incidence of 0.2%. This rate is identical to the one observed in the Mayo Clinic study and, once again, confirms that the risk of stroke associated with lone AF is extremely low – actually lower than the rate observed in the general population. Furthermore, it should be noted that 6 of the 14 patients had developed one or more risk factors for thromboembolism (5 patients with hypertension, 1 with coronary artery disease, and 2 with diabetes) by the time they experienced their stroke or other thromboembolic event. It is also of interest to note, that of the 14 patients 8 were taking aspirin, while 6 had no antithrombotic therapy. In multivariate analysis only the development of hypertension and coronary artery disease was significantly associated with thromboembolism.

During follow-up, 14 patients (4%) developed congestive heart failure (CHF) at an average 10 years from diagnosis (range of 0 to 26 years). The only variable independently associated with an increased risk of CHF in multivariate analysis was progression from paroxysmal to permanent AF. The 10-year survival of study participants was 99.6%. It is not clear from the study whether permanent AF increases the risk of CHF, or CHF increases the risk of permanent AF. The former clearly makes more sense.

The Serbian researchers conclude that the prognosis of lone AF is favourable, but becomes less so with increasing age and the development of (new) underlying heart disease.
Potpara, TS, Lip, GYH, et al. A 12-year follow-up study of patients with newly diagnosed lone atrial fibrillation: Implications of arrhythmia progression on prognosis. Chest, Vol. 141, No. 2, 2012, pp. 339-47
Boriani, G, et al. Atrial fibrillation: It is better to be alone than in bad company! Chest, Vol. 141, No. 2, 2012, pp. 290-92

Editor’s comment: The Belgrade study clearly confirms the conclusions of the Mayo Clinic study that lone AF is a benign condition with excellent long-term prognosis. The risk of stroke is extremely low even without anticoagulation, and survival rate is excellent. There is a significant trend though for paroxysmal AF to progress to persistent or permanent AF. It is, however, likely that this trend would have been significantly less pronounced if 36% of paroxysmal and persistent afibbers had not been treated with digoxin. This “medicine from hell”, for lone afibbers at least, may not only prolong episode duration, but may actually convert paroxysmal AF to permanent.[2,3]
NOTE: I personally do not agree that chronological age should enter into the definition of lone AF. This conviction is supported by the following statement by Dr. Lars Frost of the Aarhus University Hospital in Denmark, Cardiologists with strong political influence have suggested that a diagnosis of lone atrial fibrillation should be restricted to patients <60 years of age, although there is no evidence of any threshold values by age regarding the risk of stroke in patients with atrial fibrillation – or in any other medical condition for that matter.[4]

References
1. Jahangir, A, et al. Long-term progression and outcomes with aging in patients with lone atrial fibrillation. Circulation, Vol. 115, June 19, 2007, pp. 3050-56
2. Sticherling, C, et al. Effects of digoxin on acute, atrial fibrillation: Induced changes in atrial refractoriness. Circulation, Vol. 102, November 14, 2000, pp. 2503-08
3. Falk, RH. Proarrhythmic responses to atrial antiarrhythmic therapy. In Atrial Fibrillation: Mechanism and Management, edited by Rodney H. Falk and Philip J. Podrid, Lippincott-Raven Publishers, Philadelphia, 2nd edition, 1997, p. 386
4. Frost, L. Lone atrial fibrillation: Good, bad or ugly? Circulation, Vol. 115, June 19, 2007, pp. 3040-41

Hans

i found a ppt of the article Shannon was writing about. Di Biase ppt