To thin or not to thin - CHADS2

I am scheduled for ablation w/ Dr. Natale on Aug 2. After a conversation with his nurse she recommended I get on Eloquis now, due to my daily episodes of afib. My local EP said that with a CHADS2 score of 1, it isn't necessary. Is the confidence in CHADS2 well founded? I have had doctors tell me I should be on a blood thinner, and others who tell me I do not need to be on one. I don't want to have a stroke, but I don't want to take meds that aren't necessary, and have to deal with bad side effects as well. ANyone have any insight on this? My wife is also leery of me taking medication prescribed by someone other than the physician who is monitoring me locally, and knows my situation.

THanks,

Gary

The frequency of Episodes plays into this decision. The prevailing thought among the EP's that I have spoken with, is that the more episodes you have, the more anti-coagulation is advisable. If you went for a month of solid NSR, then no need for Thinners. If you haven't already, I would go back and make sure your local EP knows your AF frequency, and discuss it again. The issue with having multiple episodes even with a low Chads2 score is that every time you have episode, the Atria stops working for awhile ("Atrial Stunning"). Even though you convert back to NSR, the Atria may not start contracting right away.



Edited 1 time(s). Last edit at 05/26/2017 07:11PM by The Anti-Fib.

Gary, in my experience there is total disagreement on this issue. When my Fib/Flutter flairs up my cardiologist immediately says I should be taking the blood thinner for at least 21 days. Even when my heart converts back to NSR after a few days on its own. My CHADS2 score is ZERO. My primary care doctor says I'm crazy to take the blood thinner and the risk of a complicated bleed is greater than the risk of a stoke. I actually don't know which way to go. Both consequences scare the crap out of me. I will be interested in watching this thread progress.

Steve

I'm also a CHAD "1."

EP advised not to anti-coag. I do take supplements.

My atria stroke risk score result: "Low risk (0-5 Points), <1% annual risk of ischemic stroke."

/L

[www.mdcalc.com]

Gary, Steve , Anti-Fib and Larry,

It is critical here to understand the context in which Gary is asking about when, and if, to start on Eliquis in his current situation, leading up to an AFIB ablation

Gary is a little over two months out from his index ablation with Dr. Natale and has been asked to start the Eliquis by his nurse practitioner under Dr Natale's approval. Case closed!

This has nothing to do with CHADSVASc stroke scores in this context, it is a requirement to be fully anti-coagulated for preferably at least 6 weeks (with a minimum of 4 weeks accepted in many cases if no missed doses occurred) prior to an ablation using the gold standard 'Uninterrupted Peri-Procedural Anti-coagulation Protocol that Dr Natale also pioneered and very much promoted with the help of the Bordeaux folks, University of Penn and now nearly everybody.. Amazingly, there are still a few holdouts doing interrupted anticoagulation protocol leading up to an ablation which carries with it a clearly demonstrated in multiple rigorous large multi-center trials over the last 10 to 12 years to be inferior to the uninterrupted AC protocol in overall safety and stroke/TIA prevention both leading up to the ablation, during the ablation and over the three to four months post ablation (or longer at the discretion of the EP) that the OAC is continued post-ablation.

The out-of-date interrupted AC protocol used to start with Warfarin for a month and then stop Warfarin 5 days prior to the ablation which during those 5 days, switch the patient to doing daily low molecular weight heparin injections (known as Lovenox). Then once the ablation itself starts the patient is switched again this time to full IV Heparin in a large bolus prior to transeptal puncture (actually many EPs still doing interrupted AC used to switch to IV heparin only AFTER transeptal puncture which is NOT smart and ups the risk for emboli within the left atrium. Later that day after the ablation the patient is restarted on ramping up doses of Warfarin for 5 days along with Lovenox that he or she tapers as the Warfarin reaches full INR levels.

Uninterrupted AC, as the name implies, is using primarily one OAC the entire time .. in Gary's case Eliquis. He will take his last dose of Eliquis upon waking on the morning of his ablation and then prior to transeptal puncture into the LA he will be at least a 13,000 Unit bolus of IV Heparin that combined with the still active morning Eliquis dose will raise his ACT (activated clotting time) to around 350 seconds and a separate Nurse Practitioner in the ablation lab will be in charge of running serial ACT tests every 15 to 20 minutes the entire time any hardware remains in the LA in order to maintain the patients ACT right at 350 seconds ... (Hardware in the LA include the Lasso mapping catheter, the new Thermo-cool Smart Touch-Smart Flow ablation catheter Dr Natale will use on Gary and is his current favorite and highly versatile ablation catheter, also the two sheaths through which the two catheters will be inserted into the LA, as well as a Baylis Radio Frequency transeptal puncture needle)

At the end of the uninterrupted AC protocol ablation, all instrumentation is withdrawn from the body and the patient is given around 40mg of Protamine that will begin to reverse the extra blood thinning effect of the IV heparin and bring it down to more or less normal ELquis like levels while the patient is in recovery.

Later that day or evening the patient gets his second Eliquis of the day and then continues on twice a day Eliquis in this uninterrupted fashion until Dr Natale's NP assigned to the patient tells them it is okay to stop the OAC altogether. Generally in 4 to 6 months depending on how quiet the blanking period and right after blanking have been.

Using this Uniterrupted AC protocol has dramatically cut down the number of TIAs or strokes during or right after the ablation to almost none at all in experienced operator and centers hands.

Gary might debate starting a few weeks earlier than might technically be required prior to his first week in August ablation date, but Gary's prescriptions to start Eliqius a couple weeks early in light of his increased triggering of late is only prudent and gives him plenty of time for his body to adapt to the Eliquis and if for some very unlikely reason
he did not tolerate the drug, there would be plenty of time to switch you to Xeralto or perhaps Pradaxa which is different than Eliquis and Xeralto, both of which are Factor Xa inhibitor NOACs while Pradaxa is a Direct thrombin Inhibitor NOAC.

All in all, the recommendation makes sense and don't worry about some major complication from Eliquis.. it is highly unlikely and the odds are extremely high you won't even know you are taking it for those few initial months that you will be on the drug in the case.

I hope that answers your question and concerns Gary, the folks at St. Davids know what they are doing and no need for concern in the instance.

Cheers!
Shannon



Edited 2 time(s). Last edit at 05/29/2017 01:02PM by Shannon.

Excellent response, S!

/L

I would do what Dr Natale's nurse said.
They are very good at what they do.

Don

Thanks, Shannon for the explanation and clarification. Important information to have here as a reference link.

Also, above and beyond the question “to thin or not” relative to ablation procedures and CHADs scores, it’s especially important in terms of overall preventive health guidelines be aware of one’s blood viscosity status.

For afibbers and former afibbers not on OACs, it’s obviously a critically-important priority but non-afibbers as well need to understand the clot risk potential that often turns out to be a tragic surprise when a person suffers blockage from a clot…. commonly more predictable in those around age 55 and increasing with time and include risk factors such as genetics, smoking, obesity, diabetes, blood pressure and other inflammatory conditions, etc. However, reports show clots are happening in younger people as well.

There are many stealth, underlying conditions that promote adverse clotting tendencies; yet, often, even people actively being treated for various other ailments still are not tested appropriately to determine their blood viscosity status.

The recent post titled Clot Risk along with the older post on Thick, Sticky Blood and Risk of Stroke or Heart Attack list the lab tests that serve as viscosity indicators to help prevent these tragedies. Patients may have to be very persuasive in convincing the family doctor to order the tests but should persist until successful. Even if all you can agree upon is the Cardiac/High Sensitivity C-reaction Protein, that’s a huge plus in the area of prevention. If that number is elevated then patients must pursue labs for the other important markers as well.

If your doctors are unwilling, Life Extension Foundation has a number of test panels available which are reasonably priced and often offered at discounted prices. They work with the patient’s local Lab Corp.

Go here for LEF blood tests
[www.lifeextension.com]
[www.lifeextension.com]


Previous posts

Clot Risk [www.afibbers.org]

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

Jackie

Thanks, everyone for the insight, context and resources!