Daily Adult Aspirin for 75-Year Old / Paroxysmal Afib Stroke Prevention?

Hello -

My vastly experienced, but now older, EP recommended that I take an adult-sized (325mg) Aspirin daily for AF induced stroke prevention.

This recommendation came after I suffered three bouts of AF during a one week period in July of 2017. He also recommended that I take 200 mg of flecainide daily for the prevention of AF. After experimentation, I concluded that 100 mg of flecainide taken in the early evening was enough to keep me free from AF ever since.

My first experience with AF was in November 1994. Between that time and 2017 I had maybe 10 AF experiences usually brought on by an overindulgence of food/wine, except for two instances when I drank ice-water too fast... perhaps an overly sensitive vagus nerve!

I'm concerned with taking a full size aspirin daily after recently reading several studies thats suggesting that a daily aspirin is most likely a poor choice for older adults and the benefit‐to‐harm balance of aspirin has been further questioned. It seems to me that by taking aspirin I'm risking the very thing I'm trying to prevent... excessive bleeding/stroke and also potential digestive issues.

I am a 75-year-old male 6'4" 180 pounds. I exercise five times a week and still walk and carry my bag for 18 holes of golf three times a week.

Thank You,
Jack



Edited 1 time(s). Last edit at 08/23/2020 09:39PM by JackC.

Quote
JackC
...recommended that I take an adult-sized (325mg) Aspirin daily for AF induced stroke prevention.

Here are the 2014 guidelines [www.onlinejacc.org] You can search on aspirin. This is the most recent update: [www.ahajournals.org] Just guessing, the only thing in your [en.wikipedia.org] score would be your age.



Edited 1 time(s). Last edit at 08/23/2020 10:23PM by GeorgeN.

Quote
JackC
My vastly experienced, but now older, EP recommended that I take an adult-sized (325mg) Aspirin daily for AF induced stroke prevention.

Hi Jack, welcome to the forum.

You're right to question your highly experienced EP's advice because he hasn't kept current with his continuing medical education. His advice is wrong and dangerous. Aspirin is inferior to warfarin and all the NOACs for afib-related stroke prevention and it carries a higher bleed risk. It's the wrong drug for you to be taking (unless maybe you have other things going on you didn't mention like stents or other implanted devices).

But the question will be whether you need to be on an anticoagulant at all. Calculate your CHADS-Vasc score at the link George provided and let us know what it is.

Hi Carey, thanks for the welcome.

I've been a reader of this forum for maybe 20 years. Is that possible?

Over those many years, the information gleaned from this website has pretty much kept my AF under control. THANK YOU!

George correctly guessed my CHADS score at 1 and I don't have any contributing medical issues requiring Aspirin.

Being a CHADS 1 means taking any sort of anticoagulant is a judgement call. Could be your EP is going with a sort of old school thinking of treating aspirin as a light weight anticoagulant for someone who doesn't have a strong need for one. Trouble is, aspirin comes with a pretty significant risk of GI bleeding.

I'm in sort of a similar situation. I have a Watchman device, which means the FDA thinks I should be taking aspirin, but the guy who implanted it (Natale) doesn't agree. He thinks a "mild" anticoagulant is still a good idea, so he prescribed half-dose Eliquis. It's a good compromise. It's still effective at that dose but has a much lower bleed risk than both aspirin and full-dose Eliquis. Maybe that's a conversation you should have with your EP.

Now I’m really confused. Isn’t the sole purpose of a watchman implant after a LAA ablation is to stop NOAC altogether?

Quote
susan.d
Isn’t the sole purpose of a watchman implant after a LAA ablation is to stop NOAC altogether?

Yes, and I could do that if I wished, but I ran the choice past Natale, my local EP, and my PCP and they all agreed that continuing a half-dose of Eliquis was a good idea. As my PCP said, if you weren't taking the Eliquis I'd be telling you to take a daily baby aspirin, but the Eliquis is safer, so stick with that.

That's not because I face risks from my LAA -- I don't. It's sealed shut and can't produce clots. But because I'm a CHADS 2 and I have a history of AF, I still have a slightly increased stroke risk from other sources. It also offers protection from clots elsewhere, such as DVTs. Overall, the drug is so safe and so effective it's kind of a "why not?" decision.

Plus, side benefit: if I turn up COVID positive, I can double my dose of Eliquis and immediately have clotting protection. I won't have to wait days trying to talk someone into prescribing it. As you may be aware, widespread clotting is a huge factor in COVID and can cause widespread damage virtually anywhere/everywhere in the body.

Good point with covid19. Thank you for your time answering the question.

Last question: if you need surgery or a procedure such as a colonoscopy or ablation or dental surgery or name a scenario —would you need to bridge still since your LAA is closed off with your watchman and you are taking a low dose NOAC for other than af precautions?

Being 75 years old gives you two points on the: CHA2DS2-VASc score.

Quote
Carey
Being a CHADS 1 means taking any sort of anticoagulant is a judgement call. Could be your EP is going with a sort of old school thinking of treating aspirin as a light weight anticoagulant for someone who doesn't have a strong need for one. Trouble is, aspirin comes with a pretty significant risk of GI bleeding.

I'm in sort of a similar situation. I have a Watchman device, which means the FDA thinks I should be taking aspirin, but the guy who implanted it (Natale) doesn't agree. He thinks a "mild" anticoagulant is still a good idea, so he prescribed half-dose Eliquis. It's a good compromise. It's still effective at that dose but has a much lower bleed risk than both aspirin and full-dose Eliquis. Maybe that's a conversation you should have with your EP.

Thanks again, Carey. 🙂

When you say "half-dose Eliquis", what is your actual amount per dose/day?

One other question if I may: Considering I've been taking 100 mg Flecainide daily for over three years, do you know of any long-term potential issues regarding this drug? Is it protocol you would recommend knowing my background? This drug Flecainide) almost seems too good to be true considering the positive results, especially considering it was prescribed by the same EP who insisted I take an adult dose aspirin daily.

Quote
susan.d
Last question: if you need surgery or a procedure such as a colonoscopy or ablation or dental surgery or name a scenario —would you need to bridge still since your LAA is closed off with your watchman and you are taking a low dose NOAC for other than af precautions?

Nope. I can stop the Eliquis at any time if needed. I already stopped it for 5 days for hernia repair surgery in 2019, and again this year for 2 days for a colonoscopy. Without the Watchman, that wouldn't have been true. I would have had to do heparin bridging for both procedures.

Quote
JackC
When you say "half-dose Eliquis", what is your actual amount per dose/day?

One other question if I may: Considering I've been taking 100 mg Flecainide daily for over three years, do you know of any long-term potential issues regarding this drug? Is it protocol you would recommend knowing my background? This drug Flecainide) almost seems too good to be true considering the positive results, especially considering it was prescribed by the same EP who insisted I take an adult dose aspirin daily.

I take 2.5 mg twice daily.

Flecainide is a pretty safe, effective drug for most people. I see no reason to be concerned with you taking it. Lots and lots of people older and in poorer health than you take it for years. Its only real downside is that it may someday cease to be effective. It can do that after years of use. No way to predict whether it will, so enjoy it while it lasts.

Quote
JackC
After experimentation, I concluded that 100 mg of flecainide taken in the early evening was enough to keep me free from AF ever since.

Wondered if you'd tried an even lower dose, 50 or 75 mg? Reason I ask is the theory that an even lower dose would be less likely to lose its efficacy and would also give you more "headroom" to use on demand to convert any episodes that do come along.

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GeorgeN
Wondered if you'd tried an even lower dose, 50 or 75 mg? Reason I ask is the theory that an even lower dose would be less likely to lose its efficacy and would also give you more "headroom" to use on demand to convert any episodes that do come along.

George, thanks for your concern. Your thoughts make perfect sense...

I have not tried a lower dose than 100 mg once daily at 8:30pm.

If I were to try a lower dose, would you recommend a split regimen or once a day? BTW, are there tablets available of less than 50 mg?

Since you're only taking the flecainide once daily, is it safe to assume it's extended release? If so then you probably can't split the pills.

The smallest dose it comes in is 50 mg, so you could ask your EP to let you try that for a while. There's no advantage to going to twice daily dosing except that those would be immediate release and could be split.

Quote
JackC
Hi Carey, thanks for the welcome.

I've been a reader of this forum for maybe 20 years. Is that possible?

Over those many years, the information gleaned from this website has pretty much kept my AF under control. THANK YOU!

George correctly guessed my CHADS score at 1 and I don't have any contributing medical issues requiring Aspirin.

If you have a CHADS score of 1 you may consider nattokinase. I am 76, have CHADS score the same as you and take Nattovena, one in the morning and one last thing at night.

My sister took Aspirin for about 12 months and had a brain bleed and stroke.

Quote
Carey
Since you're only taking the flecainide once daily, is it safe to assume it's extended release? If so then you probably can't split the pills.

The smallest dose it comes in is 50 mg, so you could ask your EP to let you try that for a while. There's no advantage to going to twice daily dosing except that those would be immediate release and could be split.

I'm taking a white elliptical/oval tablet with imprint ANI on one side and 381/100 on the other. They look to be easily "splitable" with a provided center-line indentation. Not being a capsule, I would assume I have the quick-release type...

Quote
colindo

Hi Carey, thanks for the welcome.

I've been a reader of this forum for maybe 20 years. Is that possible?

Over those many years, the information gleaned from this website has pretty much kept my AF under control. THANK YOU!

George correctly guessed my CHADS score at 1 and I don't have any contributing medical issues requiring Aspirin.

If you have a CHADS score of 1 you may consider nattokinase. I am 76, have CHADS score the same as you and take Nattovena, one in the morning and one last thing at night.

My sister took Aspirin for about 12 months and had a brain bleed and stroke.

colindo, thanks for jumping in...
For starters, I'm very sorry to hear about your sister. I sincerely hope she has recovered and is doing well...

I was just about to ask if there were any proven natural alternatives v.s. pharmaceuticals for thinning your blood.

Are there tests to monitor the effectiveness of your blood-thinning protocol?



Edited 1 time(s). Last edit at 08/25/2020 07:25PM by JackC.

Quote
JackC
I'm taking a white elliptical/oval tablet with imprint ANI on one side and 381/100 on the other. They look to be easily "splitable" with a provided center-line indentation. Not being a capsule, I would assume I have the quick-release type...

Extended release drugs are often pills rather than capsules, but since the tablet is scored that definitely means it can be split. So if you want to try lowering your dose to 50 mg, you can do that easily. But 100 mg once daily was already a low dose and taking it once daily isn't the normal dosing. Immediate release flecainide is given twice daily. Does your prescription actually say once daily or did you just reduce it on your own?

Quote
JackC
I have not tried a lower dose than 100 mg once daily at 8:30pm.

If I were to try a lower dose, would you recommend a split regimen or once a day? BTW, are there tablets available of less than 50 mg?

Hi Jack,

For almost all of my nearly 16 years using flec, it has been PIP. However, there was a time going through a divorce in 2012 that I've previously written about, where I used flec prophylactically. My afib control had deteriorated and I thought it was divorce stress, but turns out it was excess calcium from the wheels of brie I was stress eating. In any case, I had 4 nights in a row with afib and they all converted with PIP flec. I went and saw my business partner's concierge cardiologist (I don't go to cardios or EP's frequently, since I'm the one who designed my afib remission program) He commented that I could take flec in advance. Like you, I took my entire dose at night, reasoning that all my episodes came in the wee hours, so that is when I needed protection. I actually started the first night with 300 mg, my PIP dose, went the next night to 200 and then titrated down from there to 0 over about 6 weeks or so. As I've posted before, I started taking ginger spice at night also. I ultimately substituted the ginger by itself for the flec. It wasn't quite as good, but nearly so. I continued that for another 6 or so months till I figured out the calcium and stopped the brie. The standard dosing theory with flec is you are trying to get to and keep a relatively constant serum level for every 24 hours. My approach was to keep the serum level the highest when my risk was highest. I assume this is your reasoning, too.

In any case, my pills are 100 mg and I would cut them to get whatever dose I wanted. I think they make smaller doses, but I've always used 100 mg pills.

If yours are cutable, I'd continue with nightly dosing, since that is working. I would slowly titrate down to see what the minimum effective dose is and then stay there. First, I'd go to 75 mg and then 50 (which IS a very low dose). Who knows? I think I recall somebody using 25 mg/day way back in the day, here. I assume you are comfortable taking the risk that you may provoke an episode if you go too low.

George

Quote
Carey

I'm taking a white elliptical/oval tablet with imprint ANI on one side and 381/100 on the other. They look to be easily "splitable" with a provided center-line indentation. Not being a capsule, I would assume I have the quick-release type...

Extended release drugs are often pills rather than capsules, but since the tablet is scored that definitely means it can be split. So if you want to try lowering your dose to 50 mg, you can do that easily. But 100 mg once daily was already a low dose and taking it once daily isn't the normal dosing. Immediate release flecainide is given twice daily. Does your prescription actually say once daily or did you just reduce it on your own?

Don't kill me, but just kinda did it on my on. My prescription initially called for 100 mg twice a day. I did that for only a couple of weeks, as I was feeling very tired/week... so I decided to try a 50 mg dose in the morning and continue with the 100 mg dose at night. Anyway, I still didn't feel the way I wanted or expected, so I eliminated the morning dose altogether. That allowed me to seemingly regain most of the energy.

Except for drinking ice-water, ALL of my AF bouts have occurred between 2:00 and 3:30 am.

Considering my background, what time would you recommend I take a 100 mg controlled-release flecainide?

Quote
GeorgeN

I have not tried a lower dose than 100 mg once daily at 8:30pm.

If I were to try a lower dose, would you recommend a split regimen or once a day? BTW, are there tablets available of less than 50 mg?

Hi Jack,

Like you, I took my entire dose at night, reasoning that all my episodes came in the wee hours, so that is when I needed protection. I actually started the first night with 300 mg, my PIP dose, went the next night to 200 and then titrated down from there to 0 over about 6 weeks or so. As I've posted before, I started taking ginger spice at night also. I ultimately substituted the ginger by itself for the flec. It wasn't quite as good, but nearly so. I continued that for another 6 or so months till I figured out the calcium and stopped the brie. The standard dosing theory with flec is you are trying to get to and keep a relatively constant serum level for every 24 hours. My approach was to keep the serum level the highest when my risk was highest. I assume this is your reasoning, too.

In any case, my pills are 100 mg and I would cut them to get whatever dose I wanted. I think they make smaller doses, but I've always used 100 mg pills.

If yours are cutable, I'd continue with nightly dosing, since that is working. I would slowly titrate down to see what the minimum effective dose is and then stay there. First, I'd go to 75 mg and then 50 (which IS a very low dose). Who knows? I think I recall somebody using 25 mg/day way back in the day, here. I assume you are comfortable taking the risk that you may provoke an episode if you go too low.

George

George, thanks very much for taking the time... 🙂

I am a bit reluctant to change anything at the moment, because I haven't taken any aspirin for about 30-days. I had some surgery done on the 5th and decided to quit altogether based on what I had read regarding aspirin issues with older adults. George, with your success controlling your AF, are you still concerned with the thickness of your blood?

Quote
JackC
George, with your success controlling your AF, are you still concerned with the thickness of your blood?

With the exception of my 2 1/2 month episode at the beginning of my afib journey, i've never taken an anticoagulant. I did for maybe 2 of those months and several weeks after I converted. I've always had a zero CHA₂DS₂-VASc score (or on the earlier incarnations). I just turned 65, so I'll get that point, but I make sure I don't have comorbidities like hypertension or blood sugar issues. As well I do other things to work on cardiovascular (i.e. blood vessel) health.



Edited 1 time(s). Last edit at 08/26/2020 10:00AM by GeorgeN.

George-doesn’t af count as a point?

Quote
JackC
Don't kill me, but just kinda did it on my on. My prescription initially called for 100 mg twice a day. I did that for only a couple of weeks, as I was feeling very tired/week... so I decided to try a 50 mg dose in the morning and continue with the 100 mg dose at night. Anyway, I still didn't feel the way I wanted or expected, so I eliminated the morning dose altogether. That allowed me to seemingly regain most of the energy.

Except for drinking ice-water, ALL of my AF bouts have occurred between 2:00 and 3:30 am.

Considering my background, what time would you recommend I take a 100 mg controlled-release flecainide?

I recommend doing what you're doing. It works for you so keep doing it!

Quote
susan.d
George-doesn’t af count as a point?

No



From [en.wikipedia.org]



Edited 1 time(s). Last edit at 08/26/2020 09:09AM by GeorgeN.

Quote
JackC
George, with your success controlling your AF, are you still concerned with the thickness of your blood?

Following on, I do a lot of things to make sure this is not an issue for me. Without doing the investigations and study I've done, I don't necessarily recommend others follow my lead.

I keep a very high Omega 3 Index (17.9% last Nov, which is a bit too high as my arms can look like I'm on warfarin with a too high INR - I beat up my arms rock climbing & etc).

I'm fanatic about keeping low insulin and low glucose. Bought my first glucometer in 2006 and made it a priority to not spike my blood sugar after eating. Subsequently (since 2009) have maintained a state of mild ketosis as a proxy for low insulin (liver won't make ketones if insulin is high). Periodic extended fasting for 7 or more days. In 2017, I did 19 cycles of fasting 5 consecutive days out of every 14 (was weight stable from day one of cycle to the next).

Maintain good BMI (24) and body fat (14%), with good strength - can do inverted pushups.

Eat a very low inflammatory diet. Test many cytokines and other metrics for inflammation and keep them very low.

Optimize exercise as I've posted about Zone 2, MAF, nasal breathing. I also use KAATSU for strength training. Per Jim Stray-Gundersen MD, this kind of training acts as "draino" for the heart. The growth hormone, VEGF and other metabolites that the training stimulates the body to excrete helps rejuvenate the endothelium.

Regular near infrared heat lamp sauna use (converted an unused shower with four 250 watt red heat lamps).

Cold exposure. Every day a cold shower, sometimes soak for 20 or more minutes in 46 deg F water.

Always breathe through nose (tape mouth at night). Work on increasing serum CO2 to allow more oxygen transfer from hemoglobin to the cells because of the Bohr effect. Breathing references:
[smile.amazon.com]
[oxygenadvantage.com]
[smile.amazon.com]
[smile.amazon.com]

The KAATSU also helps with blood pressure as does the Zona device. Maintain systolic blood pressure <120 and commonly <110. Diastolic is typically 60 or less. Keeping insulin low (fasting around 2 mIU/L) is my first take on keeping blood pressure low.

George, thanks! Does a one time only long 22 hour flight without leaving my seat much and getting dvt count as 2 points?

Quote
GeorgeN

George-doesn’t af count as a point?

No

[i.ibb.co]

From [en.wikipedia.org]

History of a thromboembolism counts for 2 points and a DVT is a thromboembolism.

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Carey
History of a thromboembolism counts for 2 points and a DVT is a thromboembolism.

Well then I don’t know if the first ER doctor with only an audible Doppler diagnosis of dvt without a screen is accurate or not. From Wednesday to Sunday I was admitted on heparin shots and also another frequent NOAC drug. I was not examined from Wednesday to Sunday morning (holiday -extremely short staffed) but instead I was stuck in a hospital bed and told not to get up or risk the clot to reach my lungs. Sunday a bunch of residents entered along with an attending who wheeled in a monitor based Doppler. The attending flatly said I was misdiagnosed and never had dvt because he couldn’t see it. They left and an hour later during discharge, the original doctor entered and stressed to me to ignore that doctor and he was 100%sure it was a dvt.

Don’t know who to believe. I was shot up 4.5 days with thinners before the second opinion. Could it had dissolved the clot in 4.5 days? It happened after day ten of flying, I had extreme pain and cramping and a warm area by the site,

But I mention it in my medical history just as a precaution. If yes it was a dvt then it raises my chads from a 3 (age, gender, high blood pressure) to a 5. Something to think about during future bridging.

Clots don't dissolve in 4-5 days unless perhaps they gave you a thrombolytic ("clot busting drugs"), but that's unlikely. So I don't know what to think of the two disagreeing doctors. I guess to be on the safe side you should assume doctor #1 was right. A DVT is pretty obvious on ultrasound so it's hard to imagine he didn't see what he said he did.

Quote
JackC

colindo, thanks for jumping in...
For starters, I'm very sorry to hear about your sister. I sincerely hope she has recovered and is doing well...

I was just about to ask if there were any proven natural alternatives v.s. pharmaceuticals for thinning your blood.

Are there tests to monitor the effectiveness of your blood-thinning protocol?

There are but they are complex.

You can do a simple test your self by pricking your finger, (before taking nattokinase) with the lancing device you would use for doing a fasting blood test...... Note how long bleeding takes to stop.

Take nattokinase and retest half hour later. You will notice a difference.
BTW. If you are a lone afibber you have the same chance of a stroke as the general public without afib.

My sister is almost ok, she now walks with a limp.



Edited 1 time(s). Last edit at 08/26/2020 04:17PM by colindo.