Anticoagulant Therapy after Successful A-Fib Catheter Ablation, Is it Right for Me?
by Steve S. Ryan, PhD
I recently received an email from Pat T., a 66-year-old very active female who was in really bad shape when she had her A-Fib attacks. She’d had a successful catheter ablation and is now A-Fib free. She wrote:
“…my EP says I need to be on anticoagulants for the rest of my life because of my CHADS2 score. He also says that an ex-A-Fib patient could go back into temporary A-Fib without knowing it and have a stroke. I’m also worried because my mother had a lot of TIAs and died of a stroke at age 85. I’d love to get off of blood thinners, but don’t want to be stupid. What are my options?”
If you are in a similar situation, you may want to read what I wrote to her:
Whether or not to go on anticoagulants is one of the most difficult decisions you and your doctor have to make. And may change over time.
Your CHADS2 score
First let’s look at your CHADS2 score.
C stands for Congestive Heart Failure which you don’t have.
H stands for Hypertension. Yours is within a normal range.
A stands for over 75 years old. You’re not that old.
D stands for diabetes which you don’t have.
S2 stands for prior stroke or TIA which you haven’t had.
As I see it, your CHADS2 risk score is zero, which means you are at a very low risk of stroke.
But the elephant in the room is your family history of stroke. This isn’t in the guidelines, but must be considered.
You’re probably more active and in better health than your mother was. But we just don’t know if stroke risk in your case is genetic.
Some guidelines would give you one point because you’re in the 65-75 year-old range. But these are guidelines and not dogma. Over 65 is questionable. It depends on one’s overall health and activity level. However, over 75 one should get risk points. Increased age definitely raises your risk of stroke. But it’s probably not age itself but what goes along with increased age like reduced activity, poor circulation and heart pumping ability, etc. that increase the risk of stroke
Women Not at Greater Risk of Stroke
CHA2DS2-VASc guidelines give any woman one point simply because of her female sex. This is counterintuitive and not borne out by research. (Also see our articles, Women in A-Fib Not at Greater Risk of Stroke! and Israeli Study—Being Female Not a Risk Factor for Stroke)
Let’s take the example of a 23-year-old female soccer player who develops A-Fib. Even though she’s in otherwise perfect health, she would be given one point on this stroke risk scale because of her female sex. (This may be a not-so-subtle form of gender bias.)
Women are not more at risk of an A-Fib stroke than men. The blood a woman loses every month thins her blood and makes her less susceptible to forming clots and having a stroke. Though once a woman enters menopause and no longer has her menstrual cycle, all too soon her risk of stroke approaches that of a man. But even in the 65-75 age range, men have more strokes than women.
Women live around five years longer than men. Because stroke is age related and women live longer than men, women do ultimately have more strokes. (Men probably would also if they lived that long.) But older women suffer these strokes not because of an inherent weakness or gender inferiority, but because they live longer.
In the US, the A-Fib field is still dominated by male doctors. Women with A-Fib tend not to be treated properly or taken seriously. They are under-diagnosed and under-treated. They are less likely to receive anticoagulation and ablation procedures as men.1
If your doctor says things like, “A-Fib is no big deal,” “It’s all in your mind,” “Take a valium,” it’s time to find a new doctor.
Some women suffer A-Fib strokes because their doctors don’t give them the attention, scrutiny and care they deserve.
Less Likely to Have an A-Fib Stroke After a Successful Catheter Ablation
Because you’ve been cured of A-Fib and are A-Fib free, the places in your heart where A-Fib normally develops have been ablated and isolated. Taking anticoagulants because you might develop A-Fib is like taking out your appendix because at some future date you might develop appendicitis (frowned upon these days).
But there is a caveat. If you have a condition that probably triggered your A-Fib, like hypertension, sleep apnea, obesity, etc. and you don’t take care of it, it’s possible you could later have a recurrence of A-Fib. Many EPs now insist that people getting an ablation lower their hypertension, get a sleep apnea study, lose weight, etc. To remain A-Fib free, you should change the condition that might have triggered or caused your A-Fib in the first place.
Studies have found that “the stroke risk over time of A-Fib patients treated with ablation was similar to patients with no history of A-Fib.”2
Once you’ve had an ablation, your stroke risk drops down to that of a normal person. This doesn’t mean you will never have a stroke. Normal people do have strokes. But because you had A-Fib in the past doesn’t mean you have an increased risk of stroke now that you are A-Fib free. As Dr. John Mandrola says, “And if there is no A-Fib, there is no benefit from anticoagulation.”3
your ep monitors for “Silent” A-Fib
“Silent” A-Fib isn’t as much a problem as in the past. Today’s A-Fib catheter ablation doctors follow their patients for long periods of time after a successful catheter ablation and use an extensive array of monitoring devices to tell if a patient is in “silent” A-Fib, such as a Zio patch which is like a Band Aid you wear for two weeks. It records day and night and captures any arrhythmia you might experience.. (For more about the Zio patch, see: A Primer: Ambulatory Heart Rhythm Monitors) It’s unlikely you’d experience a long period of silent A-Fib without your doctor being aware, though doctors and monitoring devices aren’t infallible. If you see your EP regularly for follow-up after your ablation, they would probably discover if you were in silent A-Fib.
And because your previous A-Fib symptoms were so disturbing, it’s highly unlikely that you wouldn’t notice if you suffered an A-Fib attack again. Also, a short burst of “silent” A-Fib usually isn’t going to cause a stroke. The general consensus is that it takes 24-48 hours for a clot to form when you’re in A-Fib.4 (Though I don’t know of any studies which have scientifically determined how long it actually takes for an A-Fib clot to develop.)
No one should be taking anticoagulants unless there is a real risk of stroke.
Anticoagulants risks: Not Like taking Vitamins
No one should be taking anticoagulants unless there is a real risk of stroke. Anticoagulants are not like taking vitamins. Anticoagulants have their own set of risks like hemorrhagic stroke, GI bleeds, etc. “In addition to bleeding, Pradaxa, for example, can cause stomach upset or burning, and stomach pain.” 5(These statements don’t capture the actual human toll—burning throat, roiling intestines, diarrhea, burning anus, lasting intestinal damage, etc. that Pradaxa can produce in some people.)
You can’t do activities like riding a bike. You bruise easily. When cut or in an accident, it’s harder and sometimes impossible to stop the bleeding. Anticoagulants often have other bad side effects, make you feel sick and diminish your quality of life. “Anticoagulant treatment for people with A-Fib ranks as one of the highest-risk treatments in older Americans, according to Thomas J. Moore, senior scientist at the Institute for Safe Medication Practices. “More than 15% of older patients treated for A-Fib with blood thinners for 1 year have bleeding.”6
Think of almost all medications as a type of toxin or poison. By definition they are unnatural substances that your body fights and tries to expel. Under normal circumstance, these unnatural substances are not found in your body and shouldn’t be there. The bad effects of anticoagulants are a trade-off for the reduced risk of stroke. According to Dr. David Graham of the FDA, ”Coumadin (the most used anticoagulant) provides a benefit, but it is also responsible for probably more deaths than any single drug currently marketed.”7 Sir William Osler, first chief of medicine at Johns Hopkins, made this sobering statement, “One of the first duties of the physician is to educate the masses not to take medicines.”8
One of the main reasons people get an ablation is to not have to take meds like anticoagulants for the rest of your life.
consider Natural Blood Thinners
You may want to consider taking natural anticoagulants like Nattokinase9 or Lumbrokinase.10They’ve been around for years, and their blood-thinning effects can be measured (unlike the newer medical anticoagulants). But because they are natural, they can not be patented and made into drugs by the pharmaceutical industry. Consequently most medical doctors won’t even consider them as possible patient therapy.
All too many doctors today have developed the mentality of “avoid a law suit” rather than thinking of the welfare of patients. If they put everybody on anticoagulants, patients are less likely to file a law suit that wins, even if you do have a stroke. (Even people on anticoagulants do have strokes and TIAs.) (This site is not recommending or suggesting you go off of prescription blood thinners. That would be legal suicide.)
Pharmaceutical companies (“Big Pharma”) wants everyone in the world with A-Fib to be on anticoagulants. That’s obviously how they make their money. The emphasis in today’s media is on “Living With A-Fib,” rather than getting cured or becoming A-Fib free.
Your Bottom Line
The deciding factor for you will probably not be found in the guidelines but in your family’s history of stroke, though you seem to be more active and overall healthy than probably your mother was. Will taking anticoagulants give you more peace of mind?
If you’re not happy with or don’t trust what you’re hearing from your doctors, don’t hesitate about getting a second opinion, even if you have to travel a bit to get it. This is a very important decision that you need to feel good about.
Posted May 2014
Last updated: Wednesday, May 18, 2016
- Curtis, A.B., Narasimha, D., ‘Arrhythmias in Women’ Clinical Cardiology, 2012 Mar; 36(3) URL: www.ncbi.nlm.nih.gov/pubmed/22389121↵↵
- Bunch, TJ et al. Atrial fibrillation ablation patients have long-term stroke rates similar to patients without atrial fibrillation regardless of CHADS₂ score. HeartRhythm. Volume 10, Issue 9, September 2013, Pages 1272-1277. http://www.heartrhythmjournal.com/article/S1547-5271(13)00726-1/abstract↵
- Mandrola, John. Atrial Flutter–15 facts you may want to know. In AF Ablation, Atrial fibrillation. August 5, 2013. http://www.drjohnm.org/2013/08/atrial-flutter-15-facts-you-may-want-to-know↵
- Mayet, J. et al. “Anticoagulation for cardioversion of atrial arrhythmias.” European Heart Journal, (1998)↵
- Pradaxa Fact Sheet PX81802. Last accessed March 22, 2013. URL:http://tinyurl.com/PradaxaFactSheetPX81802 ↵
- Doheney, Kathleen/ Blood Thinner Pradaxa: What You Should Know. WebMD Health News, July 25, 2014. http://www.webmd.com/stroke/news/20140725/blood-thinner-pradaxa↵
- Loudon, Manette The FDA Exposed: An Interview With Dr. David Graham, the Vioxx Whistleblower. Natural News, Tuesday, August 30, 2005. http://www.naturalnews.com/011401_Dr_David_Graham_the_FDA.html↵
- Shallenberger, Frank. Real Cures. Vol. 13, No. 7, July 2014, p.2↵
- Read more about Nattokinase at WebMD.com; last accessed May 16, 2014, URL:http://www.webmd.com/vitamins-and-supplements/nattokinase-uses-and-risks↵
- Read more about Lumbrokinase at About.com, Alternative Medicine, last accessed May 16, 2014, URL: http://altmedicine.about.com/od/herbsupplementguide/fl/Lumbrokinase.htm ↵