Any need for ANY blood thinners after Watchman implant?

HI all - I am going in to Montefiore hospital this Thursday, to have another TEE to be sure there are no leaks in or around the Watchman that was implanted this past January. Assuming there are no leaks and it is well placed, I am expecting to get off of the baby aspirin and Eliquis that I have been on since the procedure. (I had been on 5 mg. of Eliquis twice/day, which was reduced to 2.5 mg after getting the Watchman - plus the added aspirin).

I am 69 years old, in otherwise good health, and had two ablations with Dr. Natale - the last one being in 2014, eight years ago. The first ablation was a LAA isolation ablation. Been in normal sinus rhythm ever since.

I know I can get off of the aspirin and I want to get off of it. My cardiologist said all of her patients who got Watchmans are on no blood thinners. Yet I've heard a few people say there were still taking either low dose Eliquis or a baby aspirin.

I'm expecting that I will need to make that decision after this TEE, and would like to hear if there's any real need to stay on even a low dose of Eliquis. I do plan to increase my Omega 3's and some other supplements that help with blood thinning, once I am off of all thinners.

Your thoughts?

Barb

That's a question you need to pose to Natale because the answer will be different for different people. Do you need an anticoagulant because you have a Watchman that's been verified leak-free and properly seated? The answer is probably not, but there's more to consider....

I could have stopped all aspirin and Eliquis after my Watchman four years ago, but I chose to continue a half-dose of Eliquis indefinitely. I chose that route not because I think the Watchman needs it (I don't), but because the LAA isn't the only source of blood clots. Given my age (66) and my overall cardiovascular status (pretty good but "mild aortic plaque" noted on TEE), a low-dose anticoagulant seemed prudent. I think it's a safer, more effective choice than the low-dose aspirin most doctors would prescribe for me. I don't worry about the Watchman at all; I worry about arterial plaque causing clots, which all of us have if we're over 60.

So my advice would be to separate the risks in your mind. Do you need protection from the Watchman? If not, then do you need it for any other reason? The other reasons are why Natale recommended it for me and why my PCP and local EP agreed with him.

Hi Carey, I also have a Watchman, I’ll be having my 6 month TEE soon.
I have the same question in my mind regarding Eliquis.
I agree with your reasoning, except it presumes that Eliquis has no downsides.
What about, for example, possible increased risk of brain bleeds, esp. in older patients? (Or other bleeds)?
Although Eliquis is a big improvement over prior thinners/anti-coags, I’d think it still has some downsides (otherwise it would probably be good for everyone over 65 to be on it, at other full or half dose).
I’ve heard conflicting opinions from doctors.

As Carey said, the answer is different for different people.

Carey and I are about the same age, height, build with similar prior levels of exercise and we had our watchman's placed about 45 minutes apart. He's on half dose Eliquis, Dr. Natale has kept me on low dose aspirin. I suspect it is for a couple reasons - including family history of heart and cardiovascular disease.

I would think that if we aren't protected enough by the Watchman, it's been over-rated....as for the possibility of having a stroke from other areas besides the heart..isn't it true that the risk increases as we all get older? If so, they shouldn't everyone be on a blood thinner?

I am leaning towards none..my Cardiologist said none of her Watchman patients continue to take any blood thinners. But am I missing any key points?

Barb

You can go to the Boston Scientific Watchman FLX website where they offer a CHA2DS2-VASc calculator that will recommend if you should be on a blood thinner, or not.

Watchman CHA2DS2-VASc Calculator

If you are a male over the age of 75 and no other issues you get a score of 2 with the following recommendation - which I believe means a blood thinner:
- For a CHA2DS2-VASc score of 2 and higher, antithrombotic therapy is usually recommended.

The CHADS-Vasc score isn't really applicable following a Watchman implant. Regardless of your score prior to the Watchman, once you have it your risk of stroke becomes the same as people who've never had afib.

When asking if you should continue anticoagulants or aspirin following a Watchman, keep in mind that the Watchman was specifically designed for people who can't take anticoagulants. It was intended to replace anticoagulants, not work in conjunction with them. In Europe, patients rarely take any anticoagulants following a Watchman. It's only the FDA that's being overly cautious, but their recommendation isn't followed by many EPs. As I've said many times, I don't take a half-dose of Eliquis because of my Watchman. I take it for all the other causes of stroke. After 15 years in EMS, there are few things I fear more than stroke. Trust me, death isn't the worst outcome from a stroke. Not even close.

If the CHADS-Vasc score isn't really applicable following a Watchman implant then you think they would state that before you started the calculator; or there would be a question in the calculator asking if you had the Watchman implanted.

I did some research to see if the Watchman was as good as Eliquis, or similar drugs, and could not find any answers. However, I did find that there is a trial in progress to answer that very question. It is called the CHAMPION-AF clinical trial and here are 2 links to it. The information-only articles were published in 2020 and 2021.

NMMC in AFib Study: Blood Thinner vs. Device

WATCHMAN device: We lead the clinical trial

Once these trials are over we should know more about which option to take, or perhaps, take both Eliquis and implant the Watchman to reduce the risk of a stroke the most. Then the CHADS-Vasc calculator or its instructions could be officially updated.

I read it’s a tight race. Eliquis is slightly better than Xarelto and third is watchman. Neck to neck close. I’m sure the newer watchman wasn’t included in that trial a couple of years ago.

I’m happy I have a watchman. I had a severe GI bleed on full dose Eliquis and had no choice being a Chad 5-6 (depending if you count gender). Now I don’t bruise nor bleed during a dental cleaning while in half dose Eliquis which I, like Carey and others, don’t mind taking a half dose Eliquis for life. A major stroke is horrible and taking a half dose is smart insurance.

The CHADS-Vasc calculator Jackie linked to isn't something specific to the Watchman. It's a standard CHADS-Vasc score calculator and is on that site solely to help people investigating the Watchman. It's not customized for Watchman recipients. I guess they should have asked first but I suppose it never occurred to them that someone with a Watchman would be using it.

There are already multiple studies demonstrating the Watchman's safety and efficacy. It wouldn't have been approved by the FDA and its counterparts in other countries around the world if that weren't the case. I was a participant in one of the trials for the Watchman FLX in 2018 and so was another member here. Further confirmation will be nice, but it's already well established that it provides at least comparable protection as the DOACs. It's probably superior when you consider issues like patient compliance and necessary stoppages of anticoagulants. People are notoriously bad at taking drugs reliably, and sometimes those drugs have to be stopped for surgeries, etc. The Watchman has no such weaknesses.

Of course I don't want to have a stroke either, and I can understand your position on it given your experience in EMS, Carey. Do you believe that everyone over a certain age should be on Eliquis as a preventative for a stroke? I am pretty mindful of what foods and supplements can also help to thin the blood, but naturally, so that's my leaning...to increase some of those things once I am off the blood thinning meds. If I were Diabetic, obese, or had other reasons why I might be at a higher risk of a stroke, I might rethink that.

When I first had my LAA, Dr. Natale had me on 2.5 mgs. of Eliquis, and my cardiologist thought that was "nothing"...basically not helpful. It was later increased to 5mgs., but I didn't realize how bad it was to miss a dose, give my LAA...and once in a while, I did. Shannon convinced me to get the Watchman for a few reasons, but missing doses was a big one.

Thank God for this site....I would be so confused and lost during my Afib journey if I didn't have this forum to come to.

Going in for my last (?) TEE today - assuming no leaks, I'm hopeful for even better days ahead!

~ Barb

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tobherd
Do you believe that everyone over a certain age should be on Eliquis as a preventative for a stroke?

I wouldn't say everyone, but if you have a high CHADS-Vasc score and a low HAS-BLED score, a low-dose anticoagulant would likely reduce strokes overall. But I'll be surprised to see doctors prescribing them for that reason. GPs/PCPs aren't generally familiar with prescribing anticoagulants, they're expensive, and people tend to freak out over them because they vastly overestimate the dangers and imagine themselves bleeding out because of them (which actually almost never happens). I think at a minimum they'd have to have recommendations and guidelines from multiple medical authorities.

Great site Carey.

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susan.d
Great site Carey.

MDCalc.com? Yeah, that's my go-to site for all medical tests, measurements, etc.

My EP told me the same things with regard to comparing efficacy. I am having the Watchman procedure on August 30th. He said I need to be n blood thinnrs for four weeks and then baby aspirin.

Follow up TEE for Watchman DONE! No leaks or any issues found. Now waiting to hear back from either Dr. DiBiase from Montefiore, or Dr. Natale, as to what they recommend. Again, I am leaning towards no blood thinners. IF any, I would choose the low dose Eliquis, but would much prefer not that either.

It's interesting that some doctors want us to continue on low dose aspirin, but say it's OK if we decide on low dose Eliquis instead. Don't they do different things?

Barb

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tobherd
It's interesting that some doctors want us to continue on low dose aspirin, but say it's OK if we decide on low dose Eliquis instead. Don't they do different things?

Probably more accurate to say they do the same thing but in different ways.

No one has mentioned should a blood thinner be needed after a surgical LAA closure. Dr. Wolf AKA Mini Maze - feels that if the closure is surgically done properly, no anti coagulation is needed. In the years after my closure - 15 and counting, I have had various opinions if a blood thinner is needed. However, if it is needed for other reasons as you mentioned Carey, I think that deserves a conversation with the Doctor. For example if you go into afib again. BTW a few years back I asked an EP if I should get a Watchman, and he said there was no room. I feel it will be a few more years of data collecting to help folks determine the best course. Other wise, if age is a factor - everyone over 65 should be on some type of blood thinner. Same thing with taking an aspirin a day.

I can't imagine why a surgical closure of the LAA would require anticoagulants. The LAA is simply gone. How could clots form? Any surgery can cause clots in the short term, but once the sutures have healed there's nothing there for clots to form on. They're only required for a Watchman because there is foreign material in your atria exposed to the blood flow until your heart fully endothelializes over it in about 6 weeks. Foreign material directly exposed to blood flow can attract clotting. The FDA advice to continue aspirin after the first 6 weeks is just an abundance of over-caution. They've been routinely skipping that in Europe for a long time now.

I don't know what your doctor meant by saying there's "no room" for a Watchman. Unless you've had a TEE that measured the size of your LAA and found it's too small to accommodate the smallest Watchman size, or you have some unusual atrial anatomy, that makes no sense.

At the time I was told that - 3 years ago, the watchman only came in one size evidently. Some Docs think that even with a surgical LAA closure, some type of anti coagulant is warranted. There is some concern, that closures were not "complete" and some gaps may be evident or the closure was too short. That is what was explained to me. Hence as caution, blood thinners. I do not take any of these meds at the moment. I have to believe that my surgeon did a good job. However, I may in the future for other reasons - seems us Afib folks have one risk or another.