Blood thinners?

Joe can you ask about Apixaban

by Gemita - 2021-02-16 15:25:43

as a safer option?  In our experience Rivaroxaban (Xeralto) is more likely to cause bruising, nose, gastric and urinary bleeds.  My husband was switched to Apixaban with resolve of his difficult symptoms while on Rivaroxaban.  He is now on low dose Edoxaban (so am I) for atrial tachy arrhythmias.  Hubby was switched because of poor kidney function and age over 82 and because he preferred once daily dosing.

Looking at your age and permanence of your Flutter, it seems you may need to consider an anticoagulant for stroke protection, although has your doctor assessed your CHA2DS2-VASc score?  I will post a link in a minute to confirm the assessment criteria for anticoagulation.

I fought for months to stay off it but my doctors refused to treat me unless I went on anticoagulation.  I score 2 points, one for being female and one point for being over 65.  I have no heart disease also, but Flutter or Fibrillation are potentially so dangerous Joe.  They said that even a brief run of Flutter/Atrial Fibrillation, even if it only occurred once a year, was still evidence enough of my stroke risk.

30 mg Edoxaban suits me well since I am low in body weight, but the usual dose would be 60 mg once a day dosing.  Apixaban 2 x 5 mg is twice daily dosing, so not so convenient, but Apixaban is usually well tolerated and one of the safest newer anticoagulants out there and is usually the med of choice.  Check out both links!!

https://www.mdcalc.com/cha2ds2-vasc-score-atrial-fibrillation-stroke-risk

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

Apixaban

by Julros - 2021-02-16 16:38:18

I'v been taking Apixaban for almost 2 years without problem. Yes, when I get an injury it bleeds and I get a terrric bruise, but for me, its a small price to pay. I had a small stroke, which is how I found out I was in atrical flutter. I've had an ablation, but now get occaisional a fib. 

Another option is a WATCHMAN implant. It is an implanted device that blocks off the left atrial appendage. That  is the part of the heart where clots form, before they break off and travel to your head (stroke),  down a coronary artery (MI), or into a gut artery and cause an infarction. I've seen the last two occur when I worked on the cardiac floor. 

Anticoagulants

by AgentX86 - 2021-02-16 16:45:54

This is a tradeoff between the probability of ischemic stroke vs. hemorrhagic stroke.  Generally the risk of ischemic stroke is larger.  For those over 75, the best anticoagulant is apixaban (Eliquis) because of its lower risk (at least in the little testing that's been done) of hemorrhagic stroke in this group.  Even with its possibility of gastro-intestinal bleeding, doctors would rather deal with bleeding GI than a bleeding brain.

I've been on Eliquis for seven years.  It hasn't been a problem for me but it is for some and other NOACs are substituted.  With your history of bleeding, I understand your reluctance to take anticoagulation drugs but strokes are nothing to play around with.  I'd certainly have a come-to-Jesus moment with your doctors (cardiologist, EP, and PCP) and get every option on the table.  This is going to be a cost/benefit analysis that's not going to be trivial.  Your doctors will know a lot more about the trade-offs and you than we possibly could.

I've been in flutter for six years, because of heart surgery to fix Afib (Cox Maze) went sideways.  In my case, three ablations failed (didn't last as long as yours) and I was so symptomatic that I couldn't sleep without some heavy duty antiarrhythmic drugs, which damaged my sinus node (tachy/Brady and asystoles).  Since I needed a PM anyway, I decided to do an A/V ablation.  I'm still in flutter 100% of the time, though I don't feel it.  Because I'm constantly in flutter I have to be on anticoagulation, even though during the surgery, above, I had my LAA clipped.

Anticoagulation is serious stuff.  Don't decline it because you don't want to deal with some unpleasant side effects, though these may be a good reason for discontinuing them.  Your doctors should be able to evaluate the situation and give you the alternatives and odds. They're the croupiers but you're the gambler.

Joe, In your position I know what I would do ..........

by IAN MC - 2021-02-16 17:59:12

Your post brought back memories _

- Like you, I was in my seventies

- I was a fanatical exerciser ( running marathons / cycling / tennis/ golf )

- I developed atrial flutter 

 - was put on blood-thinners which I HATED

 - no diabetes,  BP normal  . No other stroke risk-factors

That's where our similarity ends because I was lucky ! I had an ablation which got my heart back into normal sinus rhythm so I came off the blood thinner within weeks.

If I still had flutter , I would have   (very reluctantly) stayed on the blood-thinner . It would have been a no-brainer . The thought of having a stroke does not appeal to me one bit !  But it is your body , you may decide to risk it.

I'm sure your cardiologist will talk you through the stroke-risk formula which Gemita mentioned, but your age and permanent flutter weigh heavily against you.

Incidentally , I am impressed by the exercise you're doing with permanent flutter.. it must be hard going.

Best of luck

Ian

Atrial Flutter

by Selwyn - 2021-02-17 12:24:12

Personally, I take Apixaban- not had any problems. Still have bit of atrial fibrillation in spite of 2 ablations for this.  

I did have a flutter ablation- this worked well. In general the complication rate of a flutter ablation is a lot less than an fibrillation ablation.  I don't know what sort of ablations you have had located in ventricles .  Flutter and fibrillation are atrial conduction disorders.

With someone so fit as yourself, I would have thought a  go at a flutter ablation would not be out of the question.  The success rate is very good. Flutter is a different animal to fibrillation- a circular conduction around the tricuspid valve (R side heart) - you only need a small burn to break the circle- a 2-3 hour job. Once successful you then will have normal  rhythm and cardiac output.  A prize worth having! The complication rate from a flutter ablation is a lot less than an atrial fibrillation (pulmonary vein isolation) ablation. 

Anticoagulation is not without its risks. As Gemita directs you to the CHADS .... score, there is also the HAS-BLED  score (https://www.mdcalc.com/has-bled-score-major-bleeding-risk).

If anyone should doubt the severity of atrial fibrillation, my Mother had paroxysmal AF, a pacemaker, a massive stroke that proved fatal in the end ( 4 weeks) in spite of being on Warfarin. Flutter is likewise associated with clot formation and embolus risk of a stroke.

I am presently cycling 100+ miles per week on no anti-arrhythmic medication. I am very grateful for my cardiac  ablations. You want to find someone to do an ablation with lots of experience. Having said that my cardiologist was more upset than me at his initial failure to complete my pulmonary vein isolation for fibrillation. 

Flutter

by thejoe056 - 2021-02-17 15:56:57

Thanks for all the feed back. I will be having heart to heart? talf with my cardiologist soon. It has been six months since my last abalation (Zaped) 50 times in the left ventricle so my heart should have calmed down by now! Legs still say GO! Heart says NO! and Brain says WHAT? My CHAD is a 2 age! Stopping that has consequences?  

I'm Sure I will figure it out. Thanks again.  Joe. 

Some notes

by AgentX86 - 2021-02-17 23:21:13

Flutter isn't always so easy to ablate successfully.  My EP had three tries and gave up.  The circuit around the tricuspid isn't the only possible source of the reentrancy.  Mine was atypical flutter (left atrium) and an odd circuit that wasn't easy to get to.  There is also an atypical flutter where the circuit is in the opposite direction around the RA.  Typical and atypical flutter is pretty easy to see on a full 12-lead EKG.

The CHA₂DS₂-VASc score is more accepted today.  A score of '0' is a contraindicatoin of anticoagulation.  A score of '1' is fielder's choice.  Above '1' and it's less risk with anticoagulation than without.  The higher the score the more the difference.  One note, the point for females is only applicable if there are points for other reasons.  IOW, other than sex, a score of '0' is '0' but a score of '1' is really a '2'.

The Watchman device is a breakthrough but it's not perfect.  About 90% of the AF/AFL clots are formed in the LAA but the remainder are not.  They're also not perfect in a number of other ways.  The Watchman isn't always installed perfectly.  A TEE is done to evaluate the velocity in the LAA to make sure it's working. 

A Watchman doesn't guarantee that anticoagulation can be stopped, either.  I have my LAA "clipped" (same function as a Watchman but done from outside the heart) but I'm still on anticoagulation for life because I'm in permanent AFL.  The risk is still too high.

AF nor AFL really affected my exercise capability.  The symptoms were awful though.  I've had an AV ablation, and even without atrial function I still do significant exercise (walk 75+ miles a week).

Flutter Ablation ... should I , shouldn't I ?

by IAN MC - 2021-02-18 05:38:08

It would be very sad if anyone with typical atrial flutter is put off having a flutter ablation because of anything they read on here.

Most EPs would agree that an ablation is now the treatment of choice for atrial flutter with success rates of over 95 %.

Atrial flutter is usually MUCH more easily ablated than A.F.  There are anatomical reasons for this. The area of flutter is usually easy to reach with a catheter and they are aiming for a thicker part of the heart which is safer to ablate.

Having a successful flutter ablation was truly life-changing for me....it may be for you too !

Ian

Flutter et al.

by Gemita - 2021-02-18 08:24:29

Hello again Joe,

You are getting some good advice from those who have been through some real ablations unlike me because I am too afraid of making my arrhythmias worse.  But I have been given encouragement and a recommendation from a member here for a really excellent EP who might be able to help me.

It sounds as though you have also been through a few ablations so you will know only too well what to expect and that they aren’t always successful, at least not the first time and may require a second or even a third ablation to fix the problem.  Some of us are just plain unlucky, aren’t we, or have particularly complicated anatomies (me) or have particularly complicated electrical systems with multiple trigger points (me), requiring potentially multiple attempts to treat the arrhythmias.  

I see from briefly looking over your history, that you may also have AF, or at least you have had episodes of AF which may not have resolved, further complicating any curative ablation for other arrhythmias, maybe even including Flutter.

I agree whole heartedly with both Ian MC and Selwyn that a typical Flutter arrhythmia can be fairly easily treated (ablated) with an excellent success rate for a complete cure, unlike Atrial Fibrillation(!), but on the other hand I also agree whole heartedly with Agent X86 that some of us will have a more complicated Flutter which will not be “typical, straightforward Flutter” and which will require more effort to fix.

Whatever you decide Joe, I hope you find the very best EP you can because until you get those arrhythmias fixed, you will always be fighting your body to perform to your best ability.  Good luck with your decision on the anticoagulant front too.  I shall personally be interested to know the outcome of your discussions with your doctors