Device Detected Afib - Blood Thinners

I have had my Medtronics 2 lead pacemaker for third degree heart block for 3 years.  I have also had two ablations for atrial flutter.  My pacemaker is now detecting small amounts of afib; less than 0.1% of the time, but rare episodes of an hour or so.  My doctor now wants me to take Eliquis because of the threat of a blood clot and stroke.  I am resisting because of the small amount of afib and the risk of this new family of blood thinners and law suits for excessive bleeding.  Is anyone else in this situation or have any advice??


6 Comments

Anticoagulation

by Gemita - 2020-09-06 16:59:34

https://en.wikipedia.org/wiki/CHA2DS2–VASc_score

Hello BobRichard,

The decision to start anticoagulation is usually based on a set of guidelines known as the CHA2DS2 VASc score.  I attach a link - hopefully it will help you to decide whether you have sufficient risk factors.  If you have, then having episodes of AF could be very dangerous without the protection of an anticoagulant.  Unfortunately it only takes a short run of AF (lasting for say no more than 20 beats I was told) to put us at considerable risk, so perhaps that is why your doctors have recommended treatment. I see you are getting episodes around one hour duration.  This could be very dangerous if you have risk factors for an AF related stroke.

My husband and I both have AF.  My husband has had several AF related strokes in the past (because he was unaware of having AF) and he was therefore unprotected.  We both though appear to have higher risk factors than you, certainly on age alone.

When I was told I needed anticoagulation I fought it with all my might since I really feared what it would do to my body but my anticoagulation clinic doctors were very kind and understanding and helped me to find the best medication for me and I have had no problems whatsoever and in fact I do not even know I am taking my anticoagulant.  

0.1% AF doesn't sound very much does it, but unfortunately that is all it takes.  Eliquis is one of the best anticoagulants to take in terms of safety.  Good luck.  I do appreciate it is a massive decision and I certainly took my time before I accepted an anticoagulant 

Also there is good evidence that apixaban is considerably safer than Vitamin-K antagonists

by crustyg - 2020-09-06 18:18:17

If I understand the literature correctly, apixaban has the best evidence base for effectiveness *and* safety (large bleeds) of the novel oral anti-coagulants and Vitamin-K antagonists (e.g. Warfarin).

You have to weigh up the very real (but not huge) risks of a stroke, compared to the really quite small risks of a major bleed due to being anticoagulated.

It's certainly wise to avoid, if you can, non-steroidal anti-inflammatory drugs if you're fully anti-coagulated with apixaban, but the risks of a major bleed are low.  Unless you know that you have a peptic ulcer, or you're continually injuring yourself due to exercise/falls/athletic activity.

It's a very personal decision and it may change over time.  I empathise with your quandry: my EP doc felt that I should also be on apixaban, *but* my CHA2DS2 score is currently 0, I'm not (yet) in AFib and I've come off my road bike at speed a couple of times in the last few years and lost quite a lot of skin, so I declined.  For the moment.

At least you and I have the luxury of being able to actually afford apixaban.  Down south from you it's a real financial challenge...

Risk is risk

by Theknotguy - 2020-09-06 18:34:26

There are times with heart problems when you want to be macho and there are times when you don't.  Kinda like when I was working on the dairy farm and we'd come across a break in the electric fence.  You didn't want to walk a half-mile back to the barn to turn off the fence and then a half-mile back.  So you'd use the heavy gloves and hope you wouldn't get nailed.  Question wasn't if you would get nailed, just when it would happen.  

Same with afib.  No one can take a look at what happens to your heart when you have afib so they can't tell you when it will be likely you'll get a blood clot in your heart.  Question isn't if, it's when.  And no one can tell you when.  It doesn't matter you're only in afib .1% of the time.  And those sessions that lasted an hour are more than enough to make a clot form. Good thing about it is when you're dead, you don't have to worry about making decisions anymore.  

You don't want a blood clot in your heart.  It isn't fun.  My heart decided to go into afib even though I was on heavy doses of heart drugs that were supposed to stop afib.  The drugs didn't stop the afib and my heart did the dipsy-doodle with no warning, the blood clot formed, and I hit the floor like a big sack of rocks.  It  took less than three seconds.  I ended up in the ER and they said, "Yep, you've got a blood clot in your heart.  Good thing you're on blood thinners.  But you need to talk to your cardiologist in the morning." What they don't tell you is the danger from the blood clot - even when you are on blood thinners - is that the danger of ending up dead lasts for about a month.  You're on heavy doses of blood thinner in an effort to dissolve the clot and until it dissolves there is a danger part of the clot will break off and you'll end up with a heart attack or a stroke.  

Take a large steel ball bearing, have a friend duct tape it just to the left of your spinal cord in the middle of your back.  Then walk around with that pushing into the middle of your back.  Then kick off a bad afib session because your heart isn't accustomed to having a foreign object inside it.  Put a gag in your mouth so you only get about 30% of the air you normally get.  Keep everything that way for 24 hours a day.  Then walk around that way for a month. Get the picture???  That's what it feels like when you have a blood clot in your heart - if you survive having the clot.  I was supposed to stay at home for a month.  Lasted for two days. Went back to work.  If I was at work and anything happened there would be someone around to know about it.  Told everyone if I was leaning against the wall gasping for air I was OK.  If I was passed out on the floor call the ambulance.  Carried extra instructions for the EMT guys in case I passed out.  Took 30 days and the clot finally dissolved.  But I don't want to live through that again.  

I've been on Eliquis for years now.  I live a normal life and problems with bleeding are minimal.  I was on coumadin - rat poison.  We used to get gallon jugs of that stuff and pour it on the seed wheat to kill off the rats.  Coumadin does pretty much the same for humans as it does for rats.  With Eliquis (Apixaban) you lead a normal life and most of the time you don't know you're on it.  Good thing about it is you get to go around and tell people how much you hate being on a blood thinner.  But, at least, you're alive to complain about it. Nuff said.
 

Choices

by AgentX86 - 2020-09-06 20:52:03

 One thing to remember about a stroke, death isn't the worst outcome.  You could be conscious and totally paralyzed - living in the solitary confinement of your body. For years.

Yes, there is a small chance of a brain bleed with a NOAC (much more with Couadin/warfarin) but there is a bigger chance of a stroke without anticoagulation.  Which do you want, a small chance of an ischemic stroke or an even smaller chance of a hemorrhagic stroke?  Either can be devastating so I'll take the "even smaller" choice. 

I was on warfarin for a few years and Eliquis for the last six years. I've had my LAA (left atrial appendage - where 90% of clots form) clipped and I'm still on Eliquis because I'm in flutter.  There is just too big of a chance of a stroke.

You're 65, so automatically have a CHADS2 score of 1, which means "dealer's choice".  If you have any of the other risks, it's foolish not to be on an anticoagulant.  If so, Eliquis is probably the best.  It has the lowest chance of bleed for older people and is considered more effective for Afibbers.  Other NOACs are recommended for stents, and such but doctors have their favorites. 

If you're worried about bleeding from injuries, Eliquis isn't a big deal and less so than warfarin. I cut myself all the time and don't notice much difference between Eliquis and nothing.  Warfarin was worse but still nothing like drinking alcohol.

Like Gemitas hubbly, I may have had very small strokes (micro-infarcts) many years ago, when I had paroxysmal and asymptomatic Afib.  I didn't know it for at least fifteen years until I had a seizure about a year ago. The MRI showed what could be some small evidence of these "micro strokes"

Your choice but my decision was pretty easy.  I'm not on board with that stroke thing.  I came close enough.

 

Eliquis or Not?

by bobrichards55 - 2020-09-07 14:16:19

Thank you all very much for your comments; very helpful.  I am CHADS-VASC of 1, based on age 65 so understandably am on the fence having no other risk factors.  I go back to my pacemaker clinic in a couple of weeks and will see how much of an afib burden I have had for the past year.  I was leaning towards staying on ASA only and trying blood thinning supplements as well for now, but you have all made me give it more thought.  Thanks again!!!

Aspirin

by Gemita - 2020-09-07 15:59:21

Bob,

Sorry but you won't be any safer with Aspirin.  Actually it is no longer recommended for AF stroke protection and may even be more harmful long term than an anticoagulant.  In any event, it is certainly not as effective as Apixaban (Eliquis) to protect against a stroke so why take it? I tried pleading with my doctors to let me take a low dose Aspirin for life instead of Apixaban, but this is what they told me . . . 

"Apixaban would be far safer long term than Aspirin.  Your decision but if we had to choose between taking Aspirin or "nothing", "nothing" would be safer"

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