To anticoagulate or not?

Hi! I'm new on the board! Have had lone afib for about 15 years, always self converting. I'm 60, have been on Flecainide for almost the entire time and recently moved so I have a new cardiologist. He keeps wanting to put me on blood thinners and cardizem along with my flec since whenever I do have afib, I have a high heart rate. I have no other symptoms when in afib other than the high heart rate. I do have hypertension which is controlled with an arb and several other health issues including GI issues. I am allergic to almost everything. Literally, I have no antibiotics that I can take at home when I get sick. Very sensitive to drugs. This cardio is going by the CHADS2 VASC that says becuz I am female and have hypertension, I should be on blood thinners. I keep refusing the cardizem becuz my reasoning is that my heart rate is fine when I'm not in afib, resting pulse usually in the low 60's. Since September of 16, I've had 2 episodes, an hour long one this Jan and a 45 minute one a week and a half ago. So I keep thinking why should I lower my rate all the time? I do have 30mg cardizem to take while I'm in afib if it goes on too long with high heart rate. I've never even tried it and cardio wants me on the long lasting dose, 180mg I think. As to alternative blood thinners, I cannot take natto becuz I'm highly allergic to soy. Am I just being stubborn becuz I don't want to take more pills with more side effects or is there some logic to my continued refusal of the cardizem and blood thinners?!

I don't know everything your Dr. is basing his advice on, but I think your approach and reasoning is sound.
Cardizem lowers BP, maybe that is on part why he wanted you to take it. The 30mg is a very low dose. It may not be enough to lower your rate during AFIB. I follow your way of thinking, I just take the Thinners and Cardizem if I have an episode. I take Cardizem 240mg XR after the Episode starts, and it takes about 30 minutes to take effect. I have to take a mild Beta-Blocker (Bystolic) also to control my rate. Normally in Lone AF, 2 short episodes lasting less than an hour would not warrant taking Thinners, as Stroke risk from brief AF is very low. Although as I said initially, I don't know your overall situation. Do you know what your Chads2 score was?



Edited 1 time(s). Last edit at 07/06/2017 05:05AM by The Anti-Fib.

Hello and welcome, LeAnn - There are other considerations in addition to the CHADS risk score that you may find useful in helping to make your decision.

My afib saga began when I was 59. The events were scattered and short at first, and then eventually, lasted much longer... often over 24 hours. I wasn't able to tolerate warfarin, so I researched what helped reduce blood viscosity and the risk for clots. I did rely on nattokinase, but also other natural substances that functioned to reduce inflammation and thus, reduce the viscosity issue.

I didn't have other health issues and didn't take any other meds... but did rely heavily on natural medicine for restorative approaches to maintaining health and especially silent inflammation that affects blood viscosity.

There are important lab tests that help determine the likelihood of hyperviscosity and my integrative/functional medicine MD did these routinely for me. These tests are listed in the report on 'Sticky, thick blood' the link is listed below.

I have MCS - multiple chemical sensitivities which make it difficult to tolerate most medications or other chemicals so I needed to feel comfortable during afib events. I'm not suggesting that you should not take a blood thinner, but because your events are few and not long lasting, thought I'd share my findings with you.

The various natural aids to help reduce viscosity include:
* Pycnogenol (Maritime pine bark extract)... check that name or look for the study on Flite Tabs that use pycnogenol to prevent deep vein thrombosis
* Serrapeptase
* Lumbrokinase
* 4 - 6 grams daily Omega 3 fish oil... pure molecularly distilled
* Ginkgo biloba
* Ginger
* Bromelain
* Vitamin C
* Curcumin... and more.
(and of course, optimal magnesium which also has anti-platelet aggregation properties along with helping to reverse the afib process). If you aren't currently using magnesium and the other supportive nutrients... please refer to The Strategy protocol at this link [www.afibbers.org]

Sticky, thick blood - risk of stroke or MI
[www.afibbers.org]
September 06, 2012

Flite Tabs [www.ncbi.nlm.nih.gov]

Let me know if I can help clarify.

Best to you,
Jackie

PS
Here's a previous post with similar info:

No one should ever be complacent about clotting risks during afib events but from our verbal/anecdotal reporting here for 17 years has generally indicated that most afibbers have been very fortunate to have had not only frequent bouts of AF but fairly long duration events as well and have avoided clot formation.

That said, emphasis should continue to be about doing all we can to make sure our blood is not “thin and slippery” which helps avoid the clotting tendency if the AF event is extended. Inflammation drives sticky blood as does elevated glucose levels as well as dehydration.

While the low dose of aspirin (81 mg) is standard recommendation, there are many other natural aids that help to ensure that platelets resist aggregation or clumping… such as magnesium, Omega 3 fish oils, C3/curcumin, Vitamin C, ginger, garlic, lycopene and, of course, the mainstay, fibrinolytic and proteolytic enzymes, such as nattokinase and lumbrokinase, serrapeptase, etc.

My history of escalating AF over eight years prior to giving in to ablation #1 and being incompatible with warfarin led my search into natural solutions that were healthy options. Fortunately, those kept me out of trouble when my events would often last 24 to 27 hours and sometimes longer. Even now, many years later, and while taking the half-dose of Eliquis, I still take much smaller doses of the natural remedies and always try to keep the inflammation marker in the low level ( HS-CRP) to avoid the negative consequences of systemic inflammation for the whole body.

We should be diligent to remind new afibbers who visit here about the importance of always making sure our blood is not “thick and sticky.”

Jackie



Edited 1 time(s). Last edit at 07/04/2017 09:50AM by Jackie.

Thanks for your reassurance that I'm not just totally crazy! LOL! My CHADS2 score is only 1 and that's for hypertension but the revised CHADS2 VASC has my score at 2 with the addition of being female! That is what my current cardio is basing his recommendation that I be on blood thinners. I know a lot of women over the age of 65 and with a CHADS2 VASC, every one of them should then be on thinners just becuz you get a point for being female and a point for being over 65. I'm not there yet but when I do reach that age, then I will have 3 points!

Thank you Jackie for all the good information. I have copied down those tests, some I have already had some of them and they were normal, but the others I will make sure to request at my next apt which is next week. I do take magnesium glycinate but can't take fish oil and I will do some research on the other items you listed. I am allergic to SO many things, both food and drugs, that I am fairly limited in what I can try. This gives me a starting point though to research and talk to my cardio about, although I am not sure he will listen. I live in a remote area and there is not a lot of choices in doctors or specialists! If you can think of anything else, I will be glad to hear from you and I thank you much for giving me some possible tools to move forward with!

LeAnn don't worry too much about the female risk most Cardio's and EPs don't unless advanced age as well goes along with being female, even still many think that this one metric of adding a point for being female is overkill.

Relative to 81mg of aspirin ... it is decidedly NOT recommended for LAA/AFIB stroke/TIA prevention at all any longer. It used to be, but many studies in recent years have completely negated and reversed that old way of thinking. Only when specific platelet aggregation inhibition is indicated like after a percutaneous stent placed in one of your coronary arteries, of another metal device is implanted within the vasculature of the heart blood vessels, does a single dose of baby aspirin have a role for generally a temporary time frame.

And while all the nutrients Jackie mentioned are all good at contributing to reduce blood viscosity, but not by necessarily taking all of them together. Though I take two soft-gel 100mg caps of Cardiokinase each day still and 100mg of Pycnogenol, and other nutrients.

Nevertheless, I would be careful mixing Nattokinase (which you noted you cant take anyway due to a soy allergy, so I mention this for other readers), Lumbrokinase and Serrapeptase all together at once, especially while still on aspirin, unless the person has a real clotting disorder in which they clot far too aggressively already, and only consider blood thinning regimes for such a case under supervision of a trusted cardiologist or EP.

Can you also please tell us over the 15 years AFIB history what is your average annual number of episodes have been and how long do they typically last each episode before converting on their own to NSR? What is the longest episodes of AFIB you have experienced and has the frequency and duration of episodes increased in recent years?? This could help us get a better feel for your potential anti-coagulation needs.

Thanks for filling in more about you AFIB history.

Best wishes!

Shannon



Edited 1 time(s). Last edit at 07/10/2017 01:24AM by Shannon.

Thanks, Shannon. I see the recommendation to stop the baby aspirin goes back several years yet many organizations like the AHA seem to continue to recommend it. Perhaps the recommendation is really only for people with existing issues.

That recommendation to discontinue use hasn't seemed to have a lot of press, at least your note above was the first I've noted.

[a-fib.com]

Gordon

Yes, of course..Thanks, Shannon.... .definitely not take all of the suggested aids all at once. I listed the options so LeAnn might find one or two with which she might be compatible.

Jackie

Thanks Jackie and yes no doubt that your list was just to choose one of two natural agents from and I agree they are all very good potential choices! I just wanted to clarify with so many new comers on the forum now to be careful not to double up on too many of potentially good things, in this case.

And that list is where I would start as well in making a careful choice for non-medical standard agents that can help lower blood viscosity too!

Thanks again Jackie,

Shannon



Edited 1 time(s). Last edit at 07/05/2017 04:33PM by Shannon.

Quote
LeAnn
Thanks for your reassurance that I'm not just totally crazy! LOL! My CHADS2 score is only 1 and that's for hypertension but the revised CHADS2 VASC has my score at 2 with the addition of being female! That is what my current cardio is basing his recommendation that I be on blood thinners. I know a lot of women over the age of 65 and with a CHADS2 VASC, every one of them should then be on thinners just becuz you get a point for being female and a point for being over 65. I'm not there yet but when I do reach that age, then I will have 3 points!

Hello LeAnn,
Can't be of much help to you, as there are many experts on this forum.
Nevertheless, many thanks for bringing this up. I'm 66 and female and have had to argue with cardiologists about the CHADS2 VASC and the statistical quirk of being a female and having one or two birthdays too many. Just wanted to let you know there are many lurkers too and very sympathetic to your situation.
All the best,
ginny

My afib history over the last 15 years has pretty much been stable. Except when I was first diagnosed and having many in and out episodes with cardizem not helping, once they put me on flecainide and realized I had a tendency to being hypokalemic, I settled in to having between 2-4 episodes a year on average. Most tended to last anywhere between 1-4 hours. At that point, and really only until the last couple of years, I was too afraid to take extra flecainide. The very longest episode I had was 11 hours. Now I know it won't hurt me to take the extra flec although I still tend to wait at least a half an hour before taking any and then it can take anywhere between a half hour to an hour to kick in. I currently take 125mg twice a day and my old cardio said I could easily go up to 300mg, so that leaves me with a whole 50mg pill to use as a safety net. Don't laugh but when I have taken the extra flec, I've cut that 50mg pill in quarters and taken just a quarter which gets me back on track!! My old cardio also said that as long as I don't make a habit out of it, I could actually go as far as 400mg in a 24 hour period as they do that in the hospital frequently. I have no tendency toward long QT so he felt that it would be safe if needed on a very occasional basis. Since Nov of 2016, I have had 2 episodes. One in Jan that lasted an hour which I took a quarter of a flec pill and one about a week and a half ago that lasted 45 minutes and converted without additional meds. In the last year since we have moved, I have developed a slight heart murmur. Echo done last Dec showed some mitral regurgitation but all chambers were of normal size, no left ventricle enlargement and EF was normal and everything else looked good. I don't know if that makes a difference or not. In the spring of 2016, I tried to wean off flecainide and go the pill in pocket method. It did not work and caused a cascade of episodes. At that point, my cardio raised my dose of the flec to my current dose and told me that pill in pocket was obviously not going to work with me. My current cardio, after my echo, told me that my afib could have caused that regurg that I now have or that the regurg could have caused that run of afib. Either way, that is my history, so I truly appreciate any and all guidance. I see this cardio again next week for my 6 mo follow up and I know he will try to scare me into going on the blood thinners and cardizem full time again, so I want to go armed with as much knowledge as I can!!

Hi LeAnn,

Just wondering if you need to be on flec all the time, or if you could taper and just use it on-demand (Pill in Pocket) when you go out of rhythm. It might take a bit more to put you back in rhythm than now, but you wouldn't be on it all the time. - Just my less is more perspective.

George

Yes I tried that George last spring. I had only gotten in to a gradual taper down process about 2-3 weeks and I started a cascade of afib episodes that were almost every day and sometimes multiple times a day. The longest episode I have ever had was during that period and I ended up having to go on a higher dose than I was prior. That put it back into control again and my cardio said that the pill in pocket method was not ever going to work for me.

Yes Gordon,

Low dose aspirin is no longer prescribed for prevention of AFIB related stroke or TIA ... in other words it is no longer used for LAA-based clot elimination ... primarily because the overwhelming weight of the evidence over the last 10 to 15 years shows the very meager impact it has on addressing AFIB embolism, is countered far more by the significantly larger risk of serious bleeding, including risk of hemorrhagic strokes.

Aspirin still has a minor role for protection from second heart attacks, though the evidence here isn't super strong, but the added bleeding risk seems to just be balanced our by enough statistical reduction in expected secondary heart attacks over time.

The one real use of aspirin, outside of its well known anti-inflammatory uses and as a pain and fever reducer for which its efficacy and risks are well known ... is its well defined role as an platelet aggregation inhibitor for use after any metallic implant in the venous or arterial blood supply is made. Such as, a PCI stent ... or a Watchman for that matter .. where in both cases either aspirin and/or Plavix ... another similar to aspirin platelet aggregation inhibitor .. is often used for a defined prior of time until the metal is considered fully endothelial-ized such that the risk of clot formation on any initially exposed metal to one's blood flow, is then essentially nil.

Hope that clarifies the changing recommendations regarding aspirin and it no longer being supported at all for AFIB related embolic risk reduction. A recent excellent large study on this issue strongly shuts the door on the feet of those who are still procrastination in stopping to prescribe aspirin to their patients, as this study underscores the very real harm that often comes from life long even low dose aspirin taken for reducing AFIB stroke risk when it does such a poor job of that task to begin with.

And you are right Gordon, it does takes time for old habits to change even .. or perhaps especially ... in medicine! Don't be surprised if we still hear of front line, smart and well-meaning cardiologists giving our aspirin to patients for AFIB stroke protection for another decade or more. The inertia of change can be very slow, particularly when something like aspirin, a gold standard of accepted therapy for so long, and some long time docs just get in a groove of doing what they always have done.

Medicine is all about peeling back the next layers of the onion and not accepting resting on our laurels .. accepting the past status quo does not foster real medical progress.


Shannon

Shannon -- Good morning!

Appreciate your clarification of the research history on ASA use in AF. I thought the critiques were much more recent than 10 to 15 years ago, but as a senior, I know how fast time can seem to pass. :>)

Which raises the question: why then have the CHADS2 / CHA₂DS₂-VASc guidelines not been modified through the years, particularly as to recommendations for anti-platelets?

Puzzling.

Do the above calculators get reviewed annually? When do you expect they'll be changed re: ASA use? Do you know why haven't been?

Curious.

Thank you.

/L

Shannon:

You said "Low dose aspirin is no longer prescribed for prevention of AFIB related stroke or TIA ... in other words it is no longer used for LAA-based clot elimination ... primarily because the overwhelming weight of the evidence over the last 10 to 15 years shows the very meager impact it has on addressing AFIB embolism, is countered far more by the significantly larger risk of serious bleeding, including risk of hemorrhagic strokes.

Serious bleeding? So all of these blood thinners that are being prescribed and taken don't cause serious bleeding? Rather confusing.

Liz

Shannon,

Additionally, I am curious as to what Eliquis does that Plavix doesn't do in the prevention of clots? When I was first diagnosed with a-fib 16 years ago, my Dr. prescribed Plavix rather than Coumadin because of my active life style and the risk of bleeding with Coumadin. I was on Plavix for 6 years, then a successful ablation 10 years ago (no a-fib since).

I am on a 91mg aspirin along with magnesium, potassium, etc. I stopped the aspirin once and my GP said I should not stop. No history of heart issue or any risk factors other than age. I do bruise easily (old thin skin), but no real problems other than the usual black and blue spots from time to time. I am 72. The Dr. that did my ablation had me on Coumadin for two weeks post ablation, but that was it. He prescribe nothing else. I had no episodes during the blanking period or any other time since.

I did not find this web site until after my ablation.

To Shannon and Jackie, who helped me so much and for everyone else's info. I have not posted since July 2014 after seeing Dr. Natale in San Diego. I don't have the horrible episodes of afib some of you do. I have a 24/7 irregular heartbeat, but have never gone to the ER. It was discovered during a routine annual physical and Holter monitor in 2010. I started with heart rate drugs, Coumadin, and started taking the recommended supplements.

I am currently still taking magnesium, fish oil, CoQ10, Vit. D and as I will explain B12. I have gone for annual echocardiograms and have had no change in my heart.

A year ago in my annual physical my blood test showed enlarged red blood cells "widely spaced." It was thought maybe anemia or possibly internal bleeding. I was told to take 1000 units of B12 daily, which I am still doing.

In October of last year I started spotting. I am currently taking Estradiol and Progesterone. I went to a gyno for an ultrasound and was told the lining of my uterus was "nice and thin" and my ovaries looked perfect as well. I had recently lost my last kitty the first part of Oct and realized that between weekly vet visits and trying to know how and when to let go, I had probably skipped dosages of my HRT. The bleeding completely stopped when I was diligent about taking them.

I just a few days ago started spotting again, still not measurable, but on and off daily. I called and have an appt for my annual physical in September. Since my ultrasound was less than a year ago I have not made another appt with gyno. Oh, also, I did a "mail in" stool test within the last 6 months and it came back negative.

My question is: If there is internal bleeding, most likely from the Xarelto, could it present in vaginal bleeding? I am positive this is not from my stool or urine. I am seriously considering switching from Xarelto to Nattokinase -- in whatever form you most recommend. I actually was on natto for several months and switched to Xarelto after seeing Dr. Natale, who recommended it. I DO remember natto slightly complicated to take (1/2 hour before meals, 20 min. after, or something like that) so also wondering if there is an easier way to take it.

I won't do anything until my appt in Sept. but, Shannon and Jackie, you were always soooo knowledgeable about hormones, etc. I thought I would get your input now. Thank you, as always, for all the help you give us.

Louise



Edited 1 time(s). Last edit at 08/15/2017 05:49PM by Louise.

Shannon,
It has been wonderful to find your A-fib forum. My situation is a little different than LeAnn’s, yet still the question is, to take a blood thinner or not. After reading all this information, I thought I would write and see if anyone could perhaps help me.

I have gone through so many emotions these past years and now I am totally confused, and scared of course, about having to make the decision of whether to begin blood thinners or remain on the 1, 325mg aspirin per day that I have been taking for stroke prevention.
I have had a-fib now for 6 years--starting with only occasional episodes( lasting from 12 - 24 hours..and later on, even more than 24 hrs.) and then continuing to get it much more often and for longer periods. I have now had permanent A-fib for about 2 years.

I am a 65 year old female. I am fortunate that my permanent a-fib is kept under control with a 50mg Extended Release Metoprolol (toprol) 2 times a day. Heart rate runs from 60’s to 80’s. I do not have any symptoms. In listening to the heartbeat with a stethoscope, steady sinus beats can be heard some of the time for several beats along with the out of rhythm beats. I do not have medical experience,and do not know if this is true, but it seems that if I have several regular beats, that the heart is doing the job of pumping the blood correctly at least some of the time, during those beats, so that it will not pool together in order to create a clot.

My Metoprolol pills however, have made me gain a lot of weight.They are not just slowing my heart down, but everything else too! I have lost a good amount of hair and I now have joint pain in my knees and hands.... All the side effects of beta blockers.
Yet, doctor says this is the best treatment. I wonder if anyone knows of another medication without these side effects that is just as safe and not worse??

My Chads score was always low. No stroke, no diabetes. Echo shows normal heart function. So, my EP prescribed 1, 325 mg aspirin a day for stroke prevention.
I have now seen on your forum that aspirin is no longer considered for prevention of a-fib strokes.
In addition, now I have turned 65. A point is also added for being female This puts me up 2 points which is a 2.2% risk per year. Although I do not get a point for diabetes, my A1C blood test showed pre-diabetes. These numbers would all say I require thinner.

They are recommending that I go on Eliquis because it has less problematic stomach upset side effects than the other thinners. From what I am reading, it has no reversal agent as does Pradaxa. Would no reversal agent be a reason not to use Eliquis???.

I also wonder if the 2.2. % risk of stroke warrants the risk of internal bleeding without a reversal agent???
I wonder if the risk of bleeding internally while on these thinners is higher or lower than the risk of stroke?

Eliquis side effects are weight gain, stiffness, muscle aches. I already have all those things from the Metoprolol. I am concerned about continuing to gain weight as I am so uncomfortable, and normal tasks have become extremely difficult. I can also hardly walk sometimes from the knee pain and stiffness.
I am also reading that Ibuprophen or Celebrex for the pain--- should not be used if you are also taking blood thinners---that they can reduce the effectiveness of the Metoprolol---and increase the risk of heart attack and stroke. Glucosamine, which is also used with good results for pain, may also increase the risk of bleeding and should not be used with aspirin or blood thinners. This is certainly a confusing array of don’ts!! What do all of you who take blood thinners take for arthritis and muscle pain ???

I dont’ know if I should just go on the blood thinner considering I have constant A-fib and now am gaining so much weight from the beta blocker.. plus all the other side effects. .... Or if I should try to hold out longer, remain on the aspirin or try other options. Because I am in constant A-fib, are Natto and Serrapeptase even an option for me? What would the dosage be for one who has A-fib all the time?

I do realize how bad a stroke can be, but I also wonder what happens from internal bleeding. If it is very serious and potentially fatal, how can there be a blood thinner on the market that has no reversal agent.??

Any advice, experience, or knowledge that anyone would be willing to share with me would be so very much appreciated. Many thanks to all.

My husband has been on warfarin for 10 years following a stroke due to atrial fibrillation. He now has a high calcium score which we can only put down to warfarin (although his consultant is in denial). He wants to start using Nattokinase but is worried that unlike warfarin he will no longer be able to measure his INR. I understand INR is not relevant with Nattokinase use, but how can we check the stroke risk - is anything measurable? Thank you.

mrsh - First, a couple of top-priority questions: What is your husband's Afib status? Age? Any other health issues such as hypertension? He shouldn't just go off warfarin and change to Nattokinase.

It is well known and documented that warfarin can and does cause elevated calcium and also calcium deposits in soft tissues. Following are some links you can read as confirmation of that.

The Vitamin K experts at University of Maastricht, Netherlands, have research this thoroughly and published numerous papers on the topic but it's often typical that cardiologists and primary care physicians are unaware of the importance of vitamin K2 in the form of menaquinone 7 or... K2 MK7 to help prevent and reverse those calcifications. (note the difference...it's not the Vitamin K 1 that is caution for use with warfarin.)

Here's a two part interview on the topic by Vitamin K expert, Leon Schurgers, PhD, that tells the story very well.
Part 1 [www.drpasswater.com]
Part 2 [www.drpasswater.com]

Now on the nattokinase, eventually if he decides to add that to the warfarin dosing, following are links here from our Conference Room that examine nattokinase and its use and some considerations and precautions.

Be sure you read these keeping in mind that they are from 2004 and updated in 2007. Not too much has changed since then but there is an improved form of nattokinase that is worth considering ... from Pure Prescriptions called Cardiokinase... go to this link read down through the details and focus on the comparison chart with the red hearts.
[www.pureprescriptions.com]

Note that initially the recommendation was for the NK form of NSK-SD. You'll see the Cardiokinase is the "new, improved version."


Read more here for background info...
Conference Room Session 39 [www.afibbers.org]
CR Session 40 [www.afibbers.org]


Also:
Soft Tissue and Coronary artery calcification

It is well known based on clinical experience alone, that Warfarin, a vitamin K antagonist increases soft tissue and arterial calcifications. Human studies confirm increased extra-coronary artery calcification induced by warfarin, an effect reversible with high Vitamin K intake. An association between low Vitamin K intake and increased risk for coronary artery disease was found in the Rotterdam Study (1-5). [jeffreydachmd.com]

I realize this is a lot of material and probably overwhelming... but important to understand.

Let me know if I can help clarify.

Jackie

Jackie - thank you so much for your detailed reply. My husband is 72. He has an enlarged heart muscle, hence the Afib, which is constant.. He was told he is not a candidate for ablation.
He gets a strange pain in his arms which we now think is due to calcium deposition. He measures his BP regularly and it is slightly high (systolic).
We are awaiting the results of an ECG and an Electron Beam computed tomography test which we should get on Thursday when he visits his consultant. We will look at all the links you have kindly supplied and in the mean time, leave off the Nattokinase until we are more informed. I will print off the research on the calcification link to warfarin and look forward to the consultant's reaction! We now just want him off that poison so shall await the consultant's proposal with interest.
Thanks again Jackie for your time and trouble in replying.