LAA, by Dr. Natale, then Watchman - did YOU stop taking Eliquis?

Happy almost New Year everyone ~

I had an LAA isolation done by Dr. Natale in Sept 2013. Needed a "touch up" in June 2014, and have been in sinus rhythm ever since (7+ years). Dr. Natale was up in NYC last January and put in my Watchman. Follow up TEE's all checked out that it was well seated and all was fine. Dr. Natale was still encouraging me to stay on low dose Eliquis....apparently because I'm 69 and strokes are more likely as we age, even if they're not Afib related. At least that's my understanding of why he recommended continuing it.

I recently starting having knee pain which turns out to be "almost" bone on bone arthritis, and was told to take a strong anti-inflammatory. Within a day or two, I had something that looked like a blood blister on my eyelid, and then a flat purplish blot the next day. I realized this might be a blood clot or bleed from the anti-inflammatory + Eliquis. I called Dr. Natale and he said it was fine for me to get off of Eliquis for the 3 weeks they wanted me on it - no worries. I have to wonder if it's just fine if I'm off of Eliquis for weeks at a time, do I really still need to be on it? I have brought this up before, but now that I'm off of Eliquis for a few weeks, I'm really doubting the need to go back on it. I mean....if it's just because I'm getting into the age group where strokes are more likely, then shouldn't everyone over a certain age be on a low dose blood thinner?

Don't scold me Carey..I know you said this is a choice. I feel that I want to stay off it, but don't want to buck Dr. Natale's recommendations either....I'd personally rather take more Omega 3's and other natural blood thinners instead. Do they not trust the Watchman enough?

Barb

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tobherd
Dr. Natale was still encouraging me to stay on low dose Eliquis....apparently because I'm 69 and strokes are more likely as we age, even if they're not Afib related. At least that's my understanding of why he recommended continuing it.

Barb, seems like you've answered your own question. It isn't Watchman risk, it is overall risk increasing with age. It is your choice, you could do a deep dive into the papers on non afib stroke risk and figure out the statistics, then make a decision.

I'm two years behind you, with no ablation or Watchman and I've never taken OAC except for a couple of months during my 2 1/2 month episode in 2004. My own reasoning is my afib burden is very low AND I'm a maniac about keeping all of my metabolic markers - like BP, insulin, A1C, glucose and so on - pristine without meds. I weigh what I did in grade 10 and am leaner now. I'm very fit, prepare all my own food and do not eat processed food. I get a raft of tests, including many on inflammation, by my longevity doc (a cardio & cardiothoracic surgeon and has a longevity practice). It would be a lot easier to take Eliquis than do what I do.



Edited 3 time(s). Last edit at 12/27/2022 07:38PM by GeorgeN.

Here is one article that looks at non afib stroke risk in the elderly. Certainly much lower than those with afib, however, it is nonzero. Also higher CHA2DS2-VASc had a higher stroke risk in non afibbers.

Even taking an OAC doesn't give a 100% risk reduction. However the reduction is very material. When I did the exercise, I looked at OAC risk reduction for those with a high CHA2DS2-VASc score vs a no OAC and a very low CHA2DS2-VASc score. From memory, having the low CHA2DS2-VASc score gave at least as good a risk reduction as having a high CHA2DS2-VASc score with OAC.. I'm not saying that taking an OAC with a low CHA2DS2-VASc would not provide additional risk reduction, it will. For me I was willing to accept the risk of a very low CHA2DS2-VASc score with a very low AF burden (my worst recent burden was 2021 at 0.7% (from memory), other than this year my afib burden has averaged around 0.02% for 18 years (after starting with a 2.5 month episode and 57% burden in the first 4 months of afib).

Oh George - you are much more meticulous than I am with all of this! I admire your dedication and success in staying in such good health.
My CHAD score is 2, and I haven't had Afib in over 7 years, and have the Watchman, so I feel like I'm a low risk. I'm not sure if that's right, but overall I am in good health (I do take meds for hypertension, which is why I get an extra point for that on the Chad). I know there are a number of ways to naturally thin the blood, albeit not as much as a Eliquis does.

Is there some sort of protocol with the Watchman implant that encourages continuation of a blood thinner - "just to be extra cautious", or is it Dr. Natale's preference - or is it just those who've had a LAA isolation? I would prefer his "blessing' to stay off Eliquis, but am not sure I"m going to get it.

Barb

As George said, the Eliquis isn't really about the Watchman. It's about your risk factors.

Just let me ask you this.... Why are you so eager to get off Eliquis? Is it that you think Eliquis is a bigger risk than stroke, or is it cost, or what? I'm not looking to scold you, I really just want to understand your thinking.

George - you really should write a book about all you know.

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Carey
As George said, the Eliquis isn't really about the Watchman. It's about your risk factors.

Just let me ask you this.... Why are you so eager to get off Eliquis? Is it that you think Eliquis is a bigger risk than stroke, or is it cost, or what? I'm not looking to scold you, I really just want to understand your thinking.

The ep who did my av ablation is insisting I stop Eliquis completely. Originally I told him Dr N said I need it for life but he still gets into a heated conversation if I explain I’m a chads 5 (6 if you count gender) and at my age and score I feel more comfortable staying on it. I won’t publicly say on this forum if I am taking it or not. Even the two EPs I interviewed abroad when we will eventually immigrate wants me on something. One suggested Plavix but when he heard I had a watchman he was fine with 2.5mg Eliquis. The second is onboard for Eliquis without any discussion. Yes my groin incision from the catheter left my worst hematoma ever but I don’t see it’s a reason to stop permanently. I was told for surgeries etc 5 days was fine off.

It’s not worth a stroke. My father had over a dozen strokes. He (in his earlier years) was a professional athlete. After his strokes he went from being in shape to being a bed bound cripple in a nursing home. I saw first hand so I don’t see why anyone would risk it.

"I'm not saying that taking an OAC with a low CHA2DS2-VASc would not provide additional risk reduction, it will. "

Some may wonder why I don't go for that additional risk reduction. It is a fair question. It is because I have a genetic risk for dementia. Given my genetics, I've been advised to consume a lot of DHA, have a very high (>12) omega 3 index as well to keep my serum plasmalogen levels > 85%ile. The plasmalogen precursors I consume are a form of omega 3. As a consequence, I already create hematomas pretty easily. As a rock climber, I'm always beating up my arms and they look like someone on warfarin with a very high INR. If I took Eliquis, I'd need to drastically reduce my intake of the omega 3's. I'm not saying the omega 3's are as effective as Eliquis for stroke prevention. I'm consuming them to mitigate a different risk. There are always tradeoffs and you can't mitigate risks 100%. If I had different genetics, I'd probably make a different decision.

So in answer to why I want to get off the Eliquis.....for several reasons. I also want to take more Omega 3's, for brain, heart and eye health. i want to be able to take an anti-inflammatory w/o worrying about a bleed from combining a blood thinner with that. There are certain herbals and supplements I want to take w/o worrying that combining those with Eliquis might cause a problem. I think the more prescriptions we are on, the more drug or herbal interactions are possible..and I'd rather not take something that isn't necessary when i'm not at a big risk for the problem it is supposed to prevent. If in fact Eliquis is recommended due to aging, then again..why don't doctors tell all their older patients to get on a blood thinner?

I know Eliquis is one of the safer blood thinners and the dose I'd be taking is low, but it still is a blood thinner. I have one grandmother who had a stroke (she was very overweight and we aren't positive it was a stroke...it was a long time ago..) and that's it. So yes, I could still have a stroke as all of us who are over a certain age have a somewhat higher risk, but if age is really the only reason, I'm not sure it's the way to go.

Not trying to argue or push my view, but isn't the point of getting a Watchman to get off of blood thinners while still being protected?

Barb



Edited 1 time(s). Last edit at 12/28/2022 10:46AM by tobherd.

I eat fatty fish daily. It has white fat stripes in the fillets. Sort of like the marbling of bacon. I also cook salmon fish soup and freeze so I can always have soup. I drizzle the fish fat from the sautéed fillet onto my gluten free bread. Probably not a good combo with Eliquis but my Berkeley Heart labs came back in the green scores not the red previously.

Not a big fish lover, so that option wouldn't work well for me...but glad it's working for you, Susan. Not sure what the green scores are referring to, but glad it's a good thing ~ Barb

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tobherd
If in fact Eliquis is recommended due to aging, then again..why don't doctors tell all their older patients to get on a blood thinner?

In the paper I linked above, "Overall, ischemic stroke incidence (per 100 person-years) was 0.35 (95 percent confidence interval [CI] = 0.34-0.35) in the non-AFib population and 1.11 (95 percent CI = 0.84-1.45) in patients with AFib (p<0.001). With increasing CHA2DS2-VASc scores, ischemic stroke incidence per 100 person-years increased in both non-AFib and AFib populations (both p value for trend, < 0.001). The relative risk ratio of ischemic stroke in the population with CHA2DS2-VASc score ≥2 was more than doubled compared to those with CHA2DS2-VASc score ≤1."

So, without an underlying condition, like afib, OAC is not indicated in the general population. I don't recall the risk reduction from OAC generally in afibbers, but 50% sticks in my mind. You've got a CHA2DS2-VASc score of 2, which doubles your risk, according to the above quote. One approach would be to see if you could become nonhypertensive, using non-drug methods. This would cut your risk in half. Non drug approaches that come to mind include lowering fasting insulin through diet, nitric oxide foods, like beetroot powder, daily hand grip isometrics at 30% of max strength for 2 x 2 minutes for each hand with a 1 minute rest between each hand) -from an Air Force pilot study in the 1970's, other regular isometric strength training, regular slow breathing exercises (6 second inhale & 6 second exhale) for 15 minutes/day. Meditation. This would (if my memory is correct) give you the same risk reduction as the OAC. I can give more info on the non med approaches, if anyone is interested.

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Not trying to argue or push my view, but isn't the point of getting a Watchman to get off of blood thinners while still being protected?

You are protected from an afib related stroke, what we are talking about is a non-afib related stroke. From my quote above, the risk is about 70% lower than an afib related stroke (though, with a CHA2DS2-VASc score of 2, you're risk is about 35% lower than an afifber).

Look at it this way, OAC is not indicated for those without afib or other underlying risks. However there is a non zero risk of a stroke, though it is low. Dr. N is giving you an opportunity to reduce this risk and most in your situation do not get this opportunity, at least to have the cost of the med covered by whatever insurance you have. It is up to you to decide if this is a good choice for you.



Edited 1 time(s). Last edit at 12/28/2022 10:00PM by GeorgeN.

George's answer is spot on, so I'll just add my personal reason for continuing Eliquis despite having a Watchman.

I received a Watchman in 2017. After I'd reached the point where the FDA protocol says stop anticoagulants and continue aspirin for life, Natale recommended half-dose Eliquis instead because it's more effective and has lower bleed risks. I took his advice to my local EP and my PCP, both of whom agreed with his recommendation. My PCP's comment was that if I weren't taking Eliquis then he would prescribe a low-dose daily aspirin. Why? Because I'm 66 and one of my TEEs revealed "mild aortic plaque" (almost everyone over 60 has some degree of aortic plaque). My local EP echoed the same thinking.

So that's why I elected to continue half-dose Eliquis indefinitely. It has absolutely no side effects for me, it protects me from clots originating anywhere in the body, it doesn't interact with many things, and it's safety profile is excellent. There is nothing that Eliquis can do to me that even begins to approach what a stroke can do to me. I spent 15 years seeing firsthand what strokes do to people, and killing them isn't even close to the worst of it. And clots don't only cause strokes; they also cause heart attacks, pulmonary embolisms, and kill tissue pretty much anywhere in the body, such as your eyes, major organs, bowels, fingers and toes, muscles... anywhere. Where a clot goes is actually rather random; it's just that a lot of blood goes to the brain and strokes are usually immediately obvious.

So I view a Watchman + 1/2 dose Eliquis as safer than a Watchman alone, and I would think that even if I were into using a lot of supplements.

Speaking of which, you voiced concerns about Eliquis interacting with supplements, but do you not have the same concerns with supplements interacting with each other? There are a number of examples of dangerous supplement combos. At least with prescription drugs you can usually look them up and find out what they interact with, but not so with supplements. You're pretty much on your own there.

Some good points made by both of you, George and Carey. Thank you for taking the time to reply.

If I'm going to be honest, I am not likely to do all of the things to lower BP naturally like you mentioned, George. I do question how big of a deal "double the risk" is when the numbers are very low to begin with...Double 1% is 2%, so that's not very concerning still, if I understand those numbers right. Also, if I haven't had Afib in 7+ years and have had a LAA isolation, am I considered an "Afibber"?

Carey - you gave a good argument for staying on Eliquis, regarding it's safety protocol and the fact that it doesn't interact with much. As for supplements, I am very well versed in that subject with over 20 years of representing a wellness manufacturer and also, about 40 years of extensive reading of all things wellness. My first husband dropped dead of a heart attack at age 37, and soon afterwards, I devoured everything I could read on health and wellness - and have been reading ever since. I also became a health coach not long ago, so am always learning more. I don't take any "weird' or unusual supplements, and only take those from trusted sources, so I am comfortable with what I am taking. What I am not sure about is how some things like Tumeric interacts with Eliquis. I want to take some supplements for the arthritis that I now have, but wanted to be sure they don't interact with it....that info is harder to find. (and of course, if I wasn't taking a blood thinner, I wouldn't have to worry about it at all). Doctors have no clue, and sometimes pharmacists don't have the answers to interactions either.

I am leaning to staying on Eliquis based on your replies here, George and Carey..but sure would like to know if I need to look up every supplement that has "blood thinning tendencies" if I'm taking low dose Eliquis too. Dr. Natale said fish oil was fine, so I'm thinking maybe not?

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tobherd
I am leaning to staying on Eliquis based on your replies here, George and Carey..but sure would like to know if I need to look up every supplement that has "blood thinning tendencies" if I'm taking low dose Eliquis too. Dr. Natale said fish oil was fine, so I'm thinking maybe not?

I've been taking fish oil for years and never stopped even on full-dose Eliquis. None of my doctors over the years have expressed any concern about that. And I don't worry about it because nobody bleeds to death because of Eliquis, fish oil, or the two combined. Really, nobody does. The fears about bleeding and anticoagulants are grossly exaggerated.

I'm glad to learn that you're well informed about supplements. That's something that always concerns me because so many people freak out about prescription drugs but then drown themselves in supplements with unknown effects and interactions with no concern.

At this point I don't think we know if the Watchman or NOACs like Eliquis are most effective against strokes. Therefore I would think that afibbers that take a NOAC and have a Watchman, like Carey, reduce their risk of a stroke vs only taking a NOAC or having a Watchman alone.

Patients hear from their EP that if they have a Watchman they may not need to take a NOAC. How do EPs know this? Has Boston Scientific (maker of the Watchman) told them so? If that is the case why would Boston Scientific sponsor a study to see which approach is most effective. If I am taking Eliquis now I would not want to switch to a different remedy if it increases my risk of a stroke.

From a previous post:

There is a NIH study underway that will determine if the Watchman is a reasonable alternative to NOACs. It is scheduled to be completed in December 2027.

CHAMPION-AF Clinical Trial - NIH US National Library of Medicine

Study Description, Brief Summary:

The primary objective of this study is to determine if left atrial appendage closure (LAAC) with the WATCHMAN FLX device is a reasonable alternative to non-vitamin K oral anticoagulants (NOACs - Xarelto, Pradaxa, Eliquis, Lixiana) in patients with non-valvular atrial fibrillation.

Actual Study Start Date : October 15, 2020
Estimated Primary Completion Date : December 2025
Estimated Study Completion Date : December 2027

Xarelto is rated #1, Eliquis is #2 and a watchman is rated #3. So according to what I read Eliquis has better protection than a watchman. That’s another reason to get a watchman and take 2.5mg Eliquis as an added overall protection.

Excellent response, Carey.

We should frame this and flag it so we can reference it often.

So that's why I elected to continue half-dose Eliquis indefinitely. It has absolutely no side effects for me, it protects me from clots originating anywhere in the body, it doesn't interact with many things, and it's safety profile is excellent. There is nothing that Eliquis can do to me that even begins to approach what a stroke can do to me. I spent 15 years seeing firsthand what strokes do to people, and killing them isn't even close to the worst of it. And clots don't only cause strokes; they also cause heart attacks, pulmonary embolisms, and kill tissue pretty much anywhere in the body, such as your eyes, major organs, bowels, fingers and toes, muscles... anywhere. Where a clot goes is actually rather random; it's just that a lot of blood goes to the brain and strokes are usually immediately obvious.

My comment: After my Natale flutter touch-up ablation in 2015, Dr. Natale said to stay on the half-dose Eliquis - for life. Even though I have a slightly low platelet count and I do bleed more easily and longer than without Eliquis, I have been able to keep most of my nutritional supplement protocols in place (based on lab evaluations Genova Diagnostics' Nutra-Eval and supervised/directed by my Board Certified Functional Medicine MD) without adverse side effects.

Jackie

Hi Jackie! Good to see you here again. Thank you for your comments. I didn't realize that the Watchman is still considered to be "iffy" in it's protection against clots. I thought it had already been determined that it was a safe alternative to blood thinners. The study you referenced is for those who still have Afib though, no? I'm confused by the title "Afibbers" for those who no longer have Afib....as we still Afibbers?

My cardiologist commented several times that she was surprised that I didn't get off of Eliquis because all of her other Watchman patients did and "that's the whole point of getting the Watchman". Which of course, made me question the need for continuing Eliquis too. That was the main reason I got the Watchman myself...and also because having had a LAA isolation, I learned that it was a big deal if I forgot even a dose of Eliquis - and I ocassionally did forget a dose.

I'm thinking that having an LAA isolation sets you apart as someone who is more susceptible to a clot, and therefore needs a little more protection that just the Watchman. Yes? I do remember my cardiologist interviewing an EP from NYC for a job in her practice here on Long Island, and he relayed a visit he had with his first patient with a LAA isolation, and it was .....ME! So apparently this kind of ablation is not that common.

I am so appreciative of all of your input on this. Thank you. This forum is incredibly helpful. ~ Barb



Edited 1 time(s). Last edit at 12/29/2022 06:09PM by tobherd.

No, it's not common, but once you have a Watchman installed your LAA becomes irrelevant whether it was ablated or not. Isolating the LAA does not increase the need for an anticoagulant once a Watchman is in place.

So your last line, Carey, basically says that taking an anticoagulant is not necessary once you have a Watchman whether you have had an ablation or not, yes? If you never had Afib, would you still want to be on low dose Eliquis now? ~ Barb

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tobherd
If you never had Afib, would you still want to be on low dose Eliquis now? ~ Barb

Yes.

My PCP had me on low-dose aspirin before my afib, and I believe that was an appropriate prescription, but that was before Eliquis even existed. Eliquis is safer and more effective than aspirin, so why wouldn't I choose it over aspirin? As for choosing nothing or supplements, I think you're kidding yourself if your CHADS score is 2 or more.

As I said before, I fear stroke far more than I fear any anticoagulant, and I think my fears are rational and medically sound.

I wished all EPs shared yours and Dr Natale’s views of remaining on Eliquis or a baby aspirin if one’s chads are >2. The EP who did my av ablation is against taking anything. It’s an unpleasant conversation if I bring it up.

Ok....got it. So I'll stay on the low dose and not worry about most supplements interacting with it. (as we also want to take care of our brain, eyes, etc. right?)

It's odd that your EP doesn't want you on Eliquis, Susan..why do you think that is? ~ Barb

Barb- It’s his personality. He is not a fan of Eliquis. I’m immigrating and have interviewed two future EPs (different cities because I’m not sure where we will be). Both want me in Eliquis. Dr Natale who I trust also wants me on 2.5 BID Eliquis. I use Eliquis’s webpage copay coupon so my cost is only $10 and it’s peace of mind to remain on it for the reasons Carey stated. My chads is 5 (6 if you add gender) with a family history for strokes. I am not medically trained and think it’s reckless if I stop.

Oh wow - that's even more surprising with such a high CHAD score and strong family history that your current EP would try to keep you off of Eliquis. I don't even see a local EP....just Dr. Natale who is thousands of miles away. I don't have a reason to see one now that I've had my (2) ablations and the Watchman. Can't you just do what both you and Dr. Natale think is best for you? I would trust him much more than any other EP, myself.
~ Barb

Barb:

I just wanted to chime in here because your way of thinking about this is exactly my way of thinking. I always thought the whole purpose of getting the Watchman device was to be able to get off blood thinners. It thought that's what the Watchman device was all about - about the promise of not needing a blood thinner.

I'm in line for my 2nd Natale ablation here in a couple weeks and if he ends up ablating my LAA, I will definitely be getting the Watchman down the road. Why? So I don't need to take blood thinners for the rest of my life!

I don't know your medical history but based on what you shared here if I were in your shoes I wouldn't hesitate to ditch the Eliquis and just be diligent with blood thinning supplements - fish oil, vitamin e, natto, garlic, etc.

I've only been on Eliquis for a week so far and I'm already going crazy wondering and worrying if I can take this or that or do this or that so I don't have a "bleeding event." I couldn't imagine being on these blood thinners for life.

If I ever end up needing the Watchman device, once it's fully sealed and "done," I won't touch a blood thinner again - unless it is needed for some other stroke risk that comes up in the future. I certainly won't take a blood thinner for a-fib at that point. I'll roll the dice all day long on the Watchman device alone and supplements - especially if I'm not longer experiencing a-fib or flutter!

Travis

Does anyone here know anyone who's experienced a serious bleeding event due to an anticoagulant?

Nope, I don't either.

I'm not sure why this scares so many people, but it's mostly a bogeyman fear. Nevertheless, I see people willing to risk a stroke because they're so terrified of a drug that almost never does what they fear so much. Meanwhile, strokes routinely do exactly what you should fear so much. The bleed risk of anticoagulants is hugely overblown and almost no one needs to modify anything in their life because they're taking an anticoagulant.



Edited 1 time(s). Last edit at 01/01/2023 05:25PM by Carey.

I take 2.5mg (half dose) but when I had my real bad covid with o2@70 I emailed my np who suggested I temporarily take 5mg. Having Eliquis in my system (half life) gave me some peace of mind to not worry about covid potential for clots until the 5mg kicked in. I didn’t up my dose for afib since I have a successful watchman but we live now in a world of covid and I wanted that added environmental protection for whatever variants pop up.

Can anyone tell me how I can find a top notch EP in my vicinity (Palm Beach County, FL) or do I have to travel further? My local cardiologist does at least one Watchman a week with outstanding success - is that good enough?
Thanks to all who run this blog and the many knowledgeable contributors - I just recently registered.
....Mel Turetzky

Any thoughts for those of us who have had a appendage stapled.?

After having a mini maze many years ago, before watchman, my surgeon and EP told me I have the same risk for strokes as someone who did not have AFIB. If you read Dr. Wolf's perspective (in TX by the way) who invented the procedure many years ago, he has his own observations about the effectiveness long term of both approaches. I did not take any anticoagulants for 16 years until recently for a different reason. There is a study going on now for people like myself who did not take anticoagulants for long periods of time and incidents of stokes after the traditional approach for closure. My cardiologist did recommend a low dose aspirin because of my age - not for the afib issue.

I did not stop Eliquis, but I cut it to a half-dose. I have a Watchman and I chose to continue half-dose Eliquis for the same reason your doc wants you taking low-dose aspirin, not because of my LAA.

I hope in our lifetime that there will be enough data to be able to make better informed decisions on the path to take. Until then, we make the best personal decision for our circumstances.

I haven't had the Watchman installed but my cardiologist insists that if I do I can stop taking eliquis. My afib is infrequent (none to notice in last 3 months, infrequent prior lasting 1 hour or less) but I don't know if that is advisable given the risk/benefit of eliquis.
Thanks for the response

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melturet
I haven't had the Watchman installed but my cardiologist insists that if I do I can stop taking eliquis. My afib is infrequent (none to notice in last 3 months, infrequent prior lasting 1 hour or less) but I don't know if that is advisable given the risk/benefit of eliquis.
Thanks for the response

More important than the frequency of your afib episodes is your CHADS-Vasc score. People have been known to experience strokes months after their last afib episode. That's one of the more bothersome aspects of afib and why there are no firm guidelines on the need for an anticoagulant based on afib frequency or duration of episodes.