Patients with ‘Valvular Atrial Fibrillation’ are often restricted from most A-Fib clinical studies and research. In particular, for NOAC trials, people with Valvular A-Fib have generally been excluded because they may have a higher rate of forming clots (e.g.: left atrial clots).
“Valvular Atrial Fibrillation” refers to those A-Fib patients with artificial heart valves or mitral stenosis.
Like most A-Fib patients, Valvular A-Fib patients with bioprosthetic or mechanical valves have to be on an anticoagulant which up to now was restricted to warfarin. So, are the new NOACs an option?
Bioprosthetic valves are non-synthetic (usually porcine) devices used to replace a defective heart valve. Compared to mechanical valves, bioprosthetic valves are less likely to cause clots, but are more prone to structural degeneration (35% fail within 15 years).
Warfarin vs Edoxaban (NOAC)
A 2017 study showed that the Novel Oral Anticoagulant (NOAC) edoxaban (brand name: Savaysa) was safer than warfarin in preventing an A-Fib stroke in people with bioprosthetic heart valves.
Edoxaban works by inhibiting factor Xa in the coagulation process. The lower dose (30 mg) was associated with a reduced rate of major bleeding, but not the higher dose (60 mg).
Compared to warfarin, edoxaban was associated with lower annual stroke rates, systemic embolic events, major bleeds, and deaths annually.
“Our analysis suggests that edoxaban appears to be a reasonable alternative to warfarin in patients with Afib and remote bioprosthetic valve implantation,” according to Dr. Robert P. Giugliano of Brigham and Women’s Hospital in Boston, MA.
Edoxaban Works With Bioprosthetic Valves But Not Mechanical Ones
For the first time, research indicates that a NOAC (edoxaban) can be used for Valvular A-Fib to prevent an A-Fib stroke―but only in the case of bioprosthetic (porcine) valves.
The NOAC, Edoxaban (Savaysa), was safer than warfarin for A-Fib patients with bioprosthetic valves.
With regards to mechanical valves, the authors cited a study in which dabigatran (Pradaxa) fared poorly in mechanical valves.
What About Other Factor Xa NOACs?
What about the other ‘factor Xa inhibitors’ such as Xarelto and Eliquis? Can they be used like edoxaban? Currently there is little clinical data on this subject. But since all three are factor Xa inhibitors, most likely they will be proven to be effective in A-Fib patients with bioprosthetic valves.
What Patients Need to Know
Do you have Valvular A-Fib and a bioprosthetic valve? Are you on warfarin? If being on warfarin is difficult for you, you now have a choice of anticoagulant. Ask your doctor about switching to the NOAC, edoxaban.
For Insidermedicine.com. Dr. Susan M. Sharma discusses why patients with atrial fibrillation turn to ablation when drug therapy doesn’t work. Presenting research findings by David J. Wilber and MD; Carlo Pappone, MD, Dr. Sharma discusses the success rates of drug therapy versus catheter ablation. (See transcript below.) (3:00 min.) Published Jan. 26, 2010 on Insidermedicine.com.
If you find any errors on this page, email us. Y Last updated: Sunday, February 19, 2017
Atrial Fibrillation patients often search for unbiased information and guidance about medicines and drug therapy treatments. These are answers to the most frequently asked questions by patients and their families. (Click on the question to jump to the answer.)
1. “ I have a heart condition. Which medications are best to control my Atrial Fibrillation?” What medications work best for me?“
2. HRT: “Do you have information about Hormone Replacement Therapy (HRT) and if it might help or hinder my atrial fibrillation?”
3. Rate Control Drug: “I take atenolol, a beta-blocker. Will it stop my A-Fib.”
1. “Is the “Pill-In-The-Pocket” treatment a cure for A-Fib? When should it be used?” (“Pill-In-The-Pocket” makes use of an antiarrhythmic drug such as flecainide)
3. “Is the antiarrhythmic drug Multaq [dronedarone] safer than taking amiodarone? How does it compare to other antiarrhythmic drugs?”
4. “My doctor told me about the Tikosyn drug option that I want to consider in getting rid of my 5-month-old persistent A-Fib. That seems like something that should be discussed on your web site.”
Note: August 2015 Update: Aspirin is no longer recommended as first-line therapy to prevent A-Fib stroke.
1. “Are anticoagulants and blood thinners the same thing? How do they thin the blood?
2. “Should everyone who has A-Fib be on a blood thinner like warfarin (brand name: Coumadin)?”
4. “I am on Coumadin (warfarin). Do I now need to avoid foods with Vitamin K which would interfere with its blood thinning effects?”
6. “I’m worried about having to take the blood thinner warfarin. If I cut myself, do I risk bleeding to death?“
Related question: “My new cardiologist wants me to switch from Pradaxa to Eliquis. if bleeding occurs, is Eliquis easier to deal with?“
Related question: “My heart doctor wants me to take Xarelto. I am concerned about the side effects which can involve death. What else can I do?”
7. “I”ve read about a new anticoagulant, edoxaban (brand names: Lixiana, Savaysa) as an alternative to warfarin (Coumadin). For A-Fib patients, how does it compare to warfarin? Should I consider edoxaban instead of the other NOACs?”
1. “I’ve had a successful catheter ablation and am no longer in A-Fib. But my doctor says I need to be on a blood thinner. I’ve been told that, even after a successful catheter ablation, I could still have “silent” A-Fib—A-Fib episodes that I’m not aware of. Is there anything I can do to get off of blood thinners?“
2. “I just had an Electrical Cardioversion. My doctor wants me to stay on Coumadin for at least one month. Why is that required? They mentioned something about a “stunned atrium.” What is that?“
A-Fib Stroke Risk
2. “The A-Fib.com web site claims that an A-Fib stroke is often worse than other causes of stroke. Why is that? If a clot causes a stroke, what difference does it make if it comes from A-Fib or other causes? Isn’t the damage the same?“
3. “How long do I have to be in A-Fib before I develop a clot and have a stroke?“
4. “Is there a way to get off blood thinners all together? I hate taking Coumadin. I know I’m at risk of an A-Fib stroke.”
FAQs A-Fib Ablations: Is it a Cure?
“I’ve read that an ablation only treats A-Fib symptoms, that it isn’t a “cure.” If I take meds like flecainide which stop all A-Fib symptoms and have no significant side effects, isn’t that a ‘cure?’”
A successful catheter ablation doesn’t just treat A-Fib symptoms, it physically changes your heart.
Isolates PVs: An ablation closes off the openings around your pulmonary veins (PVs) so A-Fib signals from the Pulmonary Veins (PVs) can no longer get into your heart. It electrically ‘isolates’ your PVs. If successful and permanent, you should be protected from developing A-Fib that originates from your PVs (where most A-Fib originates).
Recurrence Rates: Older research showed that recurrence of A-Fib after an ablation occurred at a 7% rate out to five years. But this was before the use of the newer techniques of Contact Force Sensing catheters and CryoBalloon ablation which make more permanent lesion lines around your Pulmonary Veins.
Also, people with comorbidities, like sleep apnea, obesity, diabetes, hypertension, tend to have more recurrences. Sleep apnea can cause A-Fib to develop in other parts of the heart besides the Pulmonary Veins.
Worst case scenario: But let’s discuss a worst case scenario after a successful catheter ablation. Let’s say that five years later, your A-Fib reoccurs. Usually, all that’s necessary is for a touch-up ablation to fix some gaps in the isolation burns around the openings to the PVs or other spots. It’s usually a much easier, faster procedure than your original ablation. Often, that’s all that’s necessary to keep you A-Fib free.
No Magic Pill for A-Fib: In more than 40% of cases, antiarrhythmic drugs don’t work, cause bad side effects, or lose their effectiveness over time. We don’t currently have a magic pill you can take which will guarantee to forever cure you of A-Fib.
I’m glad that flecainide works for you, but it’s not generally considered a permanent cure for A-Fib.
Catheter Ablation Only Hope of a “Cure”: The bottom line is that catheter ablation (and some surgeries) currently offers the only hope of a permanent cure of A-Fib. That doesn’t mean that all A-Fib ablations are 100% successful. Catheter ablation is a relatively new field where there is still a lot to learn. But catheter ablation is a low-risk procedure with a high rate of success. Right now, it’s the best that medical science has to offer to fix Atrial Fibrillation.
Return to FAQ Catheter Ablations
The author of Bad Pharma does an excellent job of shining a light on the truths that the drug industry wants to stay hidden.
Those truths include how they mislead doctors and the medical industry through sales techniques, and manipulate consumers into becoming life-long drug customers. (For doctors, that industry influence begins in medical school and continues throughout their practice.)
We also learn truths about the internal workings of the medical academia, the U.S. FDA, and medical journals publishing.
The arguments in the book are supported by research and data made available to the reader. The author, Ben Goldacre, is a doctor and science journalist, and advocates for sticking to the scientific method, full disclosure and advocating for the interest of the patients. Here are a few highlights from Bad Pharma.
Manipulating Clinical Drug Trials
As consumers, how do we really know which drugs are best? The U.S. FDA protects us, right? Well sort of. Read how trials for drugs and their perceived usefulness can be manipulated, poor trials go unpublished or outright suppressed, and underperforming trials are stopped early or the trial period extended.
One way to manipulate clinical trials starts at the beginning―the design of the trial. Often, few comparison studies are done. Far more common are new drug studies going against placebo pills (that everyone knows don’t work). This helps inflate findings, makes new drugs look more effective than older drugs―because they were never compared against each other.
Bad Pharma & the Cost of Doing Business
Learn how pharmaceutical companies legitimately funnel $10 million to $20 million a year to major medical journals including the New England Journal of Medicine and the Journal of the American Medical Association. So, are we surprised then that studies funded by the pharmaceutical industry are much more likely to get published by these influential journals?
Direct to Consumer Drug Advertising
Did you know drug companies spend twice as much on marketing and advertising as on researching and developing new drugs? (I was shocked.)
Of special interest to me is the ‘Direct to Consumer’ drug advertising which has significantly increased drug sales in the U.S. ‘Direct to Consumer’ drug advertising is so misleading that it is banned in all countries except two: the U.S. and New Zealand. (No wonder that 70% of drug companies’ profit comes from the U.S.)
To be specific, I hate those misleading TV commercials that target A-Fib patients. What these ads for anticoagulants don’t tell you is:
• You are on their meds for life! (they want lifelong customers!)
• These meds do nothing to treat your A-Fib (only your risk of stroke)
• A-Fib can be cured (you don’t have to be on meds for the rest of your life)
These ads for anticoagulant medications imply if you just take their pill once a day, you’ve taken care of your A-Fib. Wrong!
Well Written, Easy to Understand
Bad Pharma, is written in an easy-to-understand manner (you don’t need a medical or science degree). If you wish, you can skim through the book to get an overview, then stop and read a topic of interest. Or you can dig in for a full read, including the authors’s research and other references (documented in footnotes with citations.)
Check on Your Doctor
After reading how big Pharma may be influencing your doctor, you can now find out. In the U.S., with the passing of the Sunshine Act (part of the 2010 Patient Protection and Affordable Care Act), we can now research if a doctor has received pharma money to prescribe their products. Just go to the Open Payments or Dollars for Doctors website.
One of our tenets at A-Fib.com, is ‘Educate Yourself’! If you want to be a more savvy consumer of health care services, I highly recommend Bad Pharma. I also recommend Ben Goldacre’s other book, Bad Science.
Bonus Idea: If you pair this book with “Know Your Chances: Understanding Health Statistics” by Steven Woloshin, you’ll have a complete course on how the drug industry skillfully markets their products.
Any treatment plan for Atrial Fibrillation must address the increased risk of clots and stroke. By far the most commonly used medicine for stroke prevention is the anticoagulant warfarin (brand name Coumadin).
But warfarin is a tough drug to take long term with monthly blood tests and possible side effects. These are my top 5 articles to help you understand warfarin therapy, the associated risks and some of the alternatives.
Review these articles to learn more about Warfarin therapy:
Bonus: Video about Warfarin
Living with Warfarin: Patient Education
Excellent introduction to anticoagulant therapy with warfarin (Coumadin). Patients and medical professionals (clinical nurse, doctors, a pharmacist and clinical dietician) discuss the practical issues associated with taking warfarin. (16:22) Uploaded on Mar 7, 2011. Produced by Johns Hopkins Medicine.
An Alternative to Blood Thinners
Do you hate having to take Coumadin? Hate the monthly testing? Bothered by side effects? An alternative to taking blood thinners is closing off your Left Atrial Appendage (LAA) with the Watchman, an occlusion device. Learn more: The Watchman™ Device: The Alternative to Blood Thinners.
Don’t Expect Miracles from Current Medications
Antiarrhythmic drugs are only effective for about 40% of patients. Many patients can’t tolerate the bad side effects. When drugs do work, over time, the they become less effective or stop working. According to Drs. Savelieva and Camm:
“The plethora of antiarrhythmic drugs currently available for the treatment of A-Fib is a reflection that none is wholly satisfactory, each having limited efficacy combined with poor safety and tolerability.”
Drugs don’t cure A-Fib but merely keep it at bay.
Learn All Your Treatment Options
To start, educate yourself about Atrial Fibrillation and review all your treatment options on our page: Treatments for Atrial Fibrillation.
Next, move on to the guidelines we’ve posted: Which of the A-Fib Treatment Options is Best for Me? Then, discuss these treatment options with your doctor. This should be a ‘team effort’, a decision you and your doctor will make together.
Don’t just manage your A-Fib. Seek your Cure.
We first posted Marilyn Shook’s personal A-Fib story, “Pill-In-the-Pocket” for Five Years, then Catheter Ablation for a Cure (#25) in 2008. She then sent us updates in 2014, 2015 and now her latest update after a third ablation in late April 2016. Marilyn’s A-Fib appears to find new and unusual places to originate from.
In her lasted installment, Marilyn writes:
“It’s been a few weeks since my third PVA [Pulmonary Vein Ablation] and I am doing well.
Just to jolt your memory―I had my first PVA in 2007 and did well for 7 years. But my A-Fib returned in 2014 and was documented by a tiny Medtronic Reveal LINQ cardiac monitor implant. A second PVA followed in October of 2014.
I was A-Fib free until February 2016 when A-Fib/Flutter returned. I opted for my third PVA, which was performed in April 2016 by Dr. David Haines at Beaumont Hospital.
Marilyn Shook is also an A-Fib Support Volunteer who lives near Detroit, MI.
My Third Ablation and Post-Ablation Complication
Under general anesthesia, my PVA was extensive work but completed in about 4 hours. I was in sinus rhythm before and after the procedure. After my ablation, I was awake, alert and responsive and then suddenly became unresponsive, with thready pulse, blood pressure plummeted.
I was having a post PVA complication―a cardiac tamponade―an emergency situation!…”
Recently I corresponded with a fellow who just found out he was in “silent” Atrial Fibrillation with no symptoms.
I commend his family doctor for discovering he was in A-Fib during a routine physical. Otherwise, he might easily have had an A-Fib stroke. (Of those with untreated A-Fib, 35% will suffer a stroke.) We don’t know how long he might have been in A-Fib before being diagnosed.
I wish I could commend his cardiologist too, but I can’t. His cardiologist just put him on the rate control drug, diltiazem, and left him in A-Fib.
That is so wrong for so many reasons!
Rate control drugs aren’t really a “treatment” for A-Fib. They slow the rate of the ventricles, but they leave you in A-Fib.
Rate Control Drugs Don’t Really “Treat” A-Fib
Rate control drugs aren’t really a “treatment” for A-Fib. Though they slow the rate of the ventricles, they leave you in A-Fib. They may alleviate some A-Fib symptoms, but do not address the primary risks of stroke and death associated with A-Fib.
Effects of Leaving Someone in A-Fib
A-Fib is a progressive disease.
Leaving a patient in A-Fib can have long-term damaging effects with disastrous consequences. Atrial Fibrillation can:
• Enlarge and weaken your heart often leading to other heart problems and heart failure.
• Remodel your heart, producing more and more fibrous tissue which is irreversible.
• Stretch and dilate your left atrium to the point where its function is compromised.
• Lead to progressively longer and more frequent A-Fib episodes and within a year can progress to chronic (continuous) A-Fib.
• Increase your risk of dementia and decrease your mental abilities because 15%-30% of your blood isn’t being pumped properly to your brain and other organs.
I’m So Angry at Doctors Who Just Leave Patients in A-Fib!
I can’t tell you how angry I am at cardiologists who want to leave people in A-Fib.
Even if a patient has no apparent symptoms, just putting them on rate control meds and leaving them in A-Fib can have disastrous consequences (and verges on malpractice).
What Patients Need to Know
The goal of today’s A-Fib treatment guidelines is to get A-Fib patients back into normal sinus rhythm (NSR).
Treatment options includes antiarrhythmic drugs, chemical and electrocardioversion, catheter ablation and mini-maze surgery.
Unless too feeble, there’s no good reason to just leave someone in A-Fib.1
Don’t let your doctor leave you in A-Fib. Educate yourself. Learn your treatment options. And always aim for a Cure!
- A cardiologist may cite the 2002 AFFIRM study to justify keeping patients on rate control drugs (and anticoagulants), while leaving them in A-Fib. But this study has been contradicted by numerous other studies sinse 2002.↵
We’ve posted a new FAQ and answer about the risks of anticoagulants and three alternatives to taking them.
“I have A-Fib, and my heart doctor wants me to take Xarelto 15 mg. I am concerned about the side effects which can involve death. What else can I do?”
You are right to be concerned about the side effects of Xarelto, one of the new Novel Oral Anticoagulants (NOACs). Uncontrolled bleeding is the primary risk (patients have bled to death in the ER.)
Be advised: No anticoagulant will absolutely guarantee you will never have a stroke.
All anticoagulants are inherently dangerous. You bruise easily, cuts take a long time to stop bleeding, you can’t participate in any contact sports; there is an increased risk of developing a hemorrhagic stroke and gastrointestinal bleeding. (Most EPs are well aware of the risks of life-long anticoagulation.)
Anticoagulants cause or increase bleeding. That’s how they work. To decrease your risk of blood clots and stroke, they hinder the clotting ability of your blood. But, they also increase your risk of bleeding. But in spite of the possible negative effects of anticoagulants, if you have A-Fib and a real risk of stroke, anticoagulants do work.
What Else Can You Do? Remove the Reason for an Anticoagulant—Three Options
The best way to deal with the increased risk of stroke and side effects of anticoagulants is to no longer need them. Here are three options…<…continue… to read my full answer…>
THE TOP 10 LIST #7
Persevere-Try More Than One Treatment if Necessary
A-FIB PATIENTS’ BEST ADVICE
From Beat Your A-Fib: The Essential Guide to Finding Your Cure, Chapter 12: Your Journey to a Cure. These patients needed more than one type of treatment to become free from the burden of Atrial Fibrillation:
Joan Schneider, Ann Arbor, MI, USA, tells about starting with drug therapy:
“The Pill-in-the-Pocket (PIP) [drug therapy] served me well prior to my [catheter ablation] procedure.” (pp. 119-124)
Jay Teresi, Atlanta, GA, describes his second ablation after being A-Fib free for three-years:
“[My EP] explained that my first procedure was a success. However, during the healing process a tiny spot did not scar and this allowed the A-Fib to trip again. He ablated that portion and touched up all the other areas. I have now been free of A-Fib for over four years (as of September, 2011).” (pp. 98-100)
Harry Emmett Finch, Malibu, CA. With 40-years of A-Fib, Emmett’s treatment evolved beyond drug therapy to his PV catheter ablation, then AV Node ablation with Pacemaker and, most recently, installation of the Watchman device:
“There is more help available today than when I first developed my A-Fib [in 1972], and I’m sure more treatment options (like the Watchman device) will be available in the future.” (pp 181-189)
A-Fib is Not a One-size-fits-all Disease
Your Atrial Fibrillation is unique to you. Along with various treatments, you may need to address concurrent medical conditions (i.e, hypertension, diabetes, obesity, sleep apnea). Likewise, you may need to make lifestyle changes (e.g., diet, exercise, caffeine, alcohol, smoking).
In addition, your heart is a resilient muscle that tends to heal itself, so you may need repeated procedures.
Try More Than One Treatment if Necessary.
Learn more at: Treatments for A-Fib
‘The Top 10 List of A-Fib Patients’ Best Advice’ is a a consensus of valuable advice from fellow patients who are now free from the burden of Atrial Fibrillation. From Chapter 12, Beat Your A-Fib: The Essential Guide to Finding Your Cure by Steve S. Ryan, PhD (beatyoura-fib.com)
Next, look for #8 on the
Top 10 List of A-Fib Patients’ Best Advice
♥ Please, share the advice ♥
25. “Is the antiarrhythmic drug Multaq [dronedarone] safer than taking amiodarone? How does it compare to other antiarrhythmic drugs?”
Multaq is probably safer than amiodarone, but it isn’t just “amiodarone-lite.”
Higher Death Rates with Dronedarone
Some studies indicate Multaq by Sanofi-Aventis (generic name: dronedarone) has its own set of problems.
In a study of dronedarone in high-risk patients with permanent A-Fib (PALLAS-3,236 patients), patients taking dronedarone were dying at more than twice the rate of those on a placebo. The ratio of stroke and hospitalization for heart failure was also more than twice as high.
The EMA recommends dronedarone not be used in patients still in A-Fib.
Dronedarone Shouldn’t Be Used in Patients in A-Fib
The European Medicines Agency (EMA) has recommended that the antiarrhythmic drug dronedarone not be used in patients still in A-Fib, that it should be discontinued if A-Fib reoccurs, that it shouldn’t be used in patients who have previous liver or lung injury following treatment with amiodarone, and that patients using it should have their liver and lung functions regularly monitored.
Who Should be Taking Dronedarone (If Anyone)?
The Committee for Medicinal Products for Human Use (CHMP) of the EMA said that dronedarone may be a useful option in patients who are in sinus rhythm after a successful cardioversion. But even in this case, dronedarone should only be prescribed after alternate treatment options have been considered.
…Dronedarone should only be prescribed after alternate treatment options have been considered.
About dronedarone, noted A-Fib blogger, Dr. John Mandrola wrote, “I’m surprised that the drug has persisted. I don’t know any of my colleagues who would start a patient out on Multaq [dronedarone]. It just doesn’t work.”
According to these studies and news reports, no one with any type of A-Fib should be taking dronedarone (Multaq).
This is a major change in treatment options for patients with A-Fib.
Dronedarone may be associated with increased strokes, hospitalizations, heart failure, liver damage, lung damage and death. And it may not be very effective anyway.
No antiarrhythmic drug is 100% safe and effective for all A-Fib patients. But until we get more favorable research on dronedarone, all patients with A-Fib should consider not taking it and try alternative options.
Connolly SJ. Dronedarone in High-Risk Permanent Atrial Fibrillation. PALLAS Clinical trial (Permanent Atrial Fibrillation Outcome Study Using Dronedarone on Top of Standard Therapy). New England Journal of Medicine, 2011; 365: 2268-76. http://www.nejm.org/doi/full/10.1056/NEJMoa1109867 DOI: 10.1056/NEJMoa1109867
O’Riordan, Michael. “EMA recommends restricting use of dronedarone” HeartWire, Sept. 22, 2011. http://www.medscape.com/viewarticle/750196
Burton, Thomas M., FDA Reviews Heart-Rhythm Drug. The Wall Street Journal, September 22, 2011. http://www.wsj.com/articles/SB10001424053111904563904576585091471862916
The European Medicines Agency (EMA): a decentralised agency of the European Union (EU) is responsible for the scientific evaluation, supervision and safety monitoring of medicines developed by pharmaceutical companies for use in the EU. http://www.ema.europa.eu/ema/; See: Multaq/dronedarone
Last updated: Wednesday, May 25, 2016 Return to FAQ Drug Therapies
Third in my series from the Ninth Annual Western Atrial Fibrillation Symposium held February 26-27, 2016 in Park City, UT. Read my other reports here.
If you have A-Fib, it’s important to realize that not all strokes are ‘A-Fib related’. You may be perfectly anticoagulated or have a Watchman Device installed and still experience a stroke.
Realize: an A-Fib patient can have a stroke that isn’t caused by A-Fib.
Dr. Jennifer Majersik of the Stroke Center of the Un. of Utah described the case of a man with A-Fib who had an ischemic stroke even though his INR on warfarin was in the correct range.
An A-Fib patient can have a stroke that isn’t caused by A-Fib. There are multiple mechanisms which can cause a stroke. Of the 690,000 strokes in the US/year nearly 1/3 are cryptogenic (of unknown cause) and of those 30% is caused by asymptomatic or Silent A-Fib.
Recently I got good news from Joann Sickinger. She wrote me about controlling her A-Fib with drug therapy. She has been almost A-Fib free for 2 years and has not experienced any side effects.
She has been taking Multaq (dronedarone) 400 mg twice a day, along with metoprolol 12 1/2 mg once a day and Xarelto 15 mg once a day.
Joann says “I am not sure how long this will last and will opt for ablation if I start having attacks again.”
Thanks, Joann for sharing. I’m glad you are aware that drugs often stop working over time and that you are prepared to have a catheter ablation if that happens. (With a successful ablation, you may be able to stop all medications.) We wish you continued good heart health!
Joann invites your email about Multaq. You can reach her at: joannbday(at)aol.com
Do you have a drug therapy story to share?
Are drugs working for you? Are your A-Fib symptoms under control? Or, have A-Fib drugs been ineffective or with side effects? Email us and share your experiences with our A-Fib.com readers.
24. “I have A-Fib, and my heart doctor wants me to take Xarelto 15 mg. I am concerned about the side effects which can involve death. What else can I do?”
You are right to be concerned about the side effects of Xarelto, one of the new Novel Oral Anticoagulants (NOACs).
All anticoagulants are inherently dangerous. You bruise easily, cuts take a long time to stop bleeding, you can’t participate in any contact sports; there is an increased risk of developing a hemorrhagic stroke and gastrointestinal bleeding. “Oral anticoagulants are high-risk medications” (Drs. Witt & Hansen) (Most EPs are well aware of the risks of life-long anticoagulation.)
Primary risk: Uncontrolled bleeding is the primary risk (patients have bled to death in the ER.) Anticoagulants cause or increase bleeding. That’s how they work. To decrease your risk of blood clots and stroke, they hinder the clotting ability of your blood. But, they also increase your risk of bleeding.
Normally, clotting is a good thing like when you have a scrape or cut.
Other risks: Do the NOACs have the same long-term problems as warfarin (Coumadin), i.e., microbleeds in the brain, hemorrhagic stroke, early dementia, etc.?
We don’t know yet. The NOACs haven’t been around long enough to determine their long-term side effects. But intuitively one would expect so. (The recent spate of ads from lawyers seeking clients who have been harmed by NOACs would seem to lead to this conclusion.)
Anticoagulants Protect You and Give Peace of Mind
But in spite of the possible negative effects of anticoagulants, if you have A-Fib and a real risk of stroke, anticoagulants do work. You’re no longer 4–5 times more likely to have an A-Fib (ischemic) stroke. Taking an anticoagulant to prevent an A-Fib stroke also may give you peace of mind.
What Else Can You Do? Remove the Reason for an Anticoagulant—Three Options
Be advised: No anticoagulant will absolutely guarantee you will never have a stroke.
The best way to deal with the increased risk of stroke and side effects of anticoagulants is to no longer need them. Here are three options:
#1 Alternative: Get rid of your A-Fib.
As EP and prolific blogger Dr. John Mandrola wrote: “…if there is no A-Fib, there is no benefit from anticoagulation.”
Action: Request a catheter ablation procedure. Today, you can have an ablation immediately (called ‘first-line therapy’). You don’t have to waste a year on failed drug therapies. See Catheter Ablation Reduces Stroke Risk Even for Higher Risk Patients
#2 Alternative: Close off your Left Atrial Appendage (LAA).
The Left Atrial Appendage is where 90%-95% of A-Fib clots originate.
Action: Request a Watchman device. The Watchman device is inserted to close off your LAA and keep clots from entering your blood stream. See Watchman Better Than Lifetime on Warfarin
#3 Alternative: Consider non-prescription blood thinners
Ask your doctor about your CHA2DS2-VASc score (a stroke risk assessor). If your score is a 1 or 2 (out of 10), ask if you could take a non-prescription approach to a blood thinner.
Perhaps you can benefit from an increase in natural blood thinners such as turmeric, ginger and vitamin E or, especially, the supplement Nattokinase. See FAQ: “Are natural blood thinners as good as prescription blood thinners?”
Whether or not to take anticoagulants (and which one) is one of the most difficult decisions you and your doctor must make. Talk to your doctor about alternatives to anticoagulants: Taking an anticoagulant isn’t like taking a daily vitamin. Only take one if you are at a real risk of stroke.
Taking an anticoagulant isn’t like taking a daily vitamin. Only take one if you are at a real risk of stroke.
• Catheter ablation
• LAA closure (Watchman device)
• Non-prescription blood thinners
If you decide to stay on a NOAC, ask your doctor about taking Eliquis instead of Xarelto. Eliquis tested better than the other NOACs and is considered safer. See Warfarin vs. Pradaxa and the Other New Anticoagulants and the FAQ: Is Eliquis Safer.
Thanks to Jim Lewis for this question.
Witt, Daniel W. and Hansen, Alisyn L. editorial in New Oral Anticoagulants Can Require Careful Dosing Too. by Scott Baltic. Medscape/Reuters Health Information, December 29, 2016. http://www.medscape.com/viewarticle/873821?src=wnl_edit_tpal
You must be your own best patient advocate.
Don’t settle for a lifetime on anticoagulants or blood thinners.
Last updated: Sunday, January 1, 2017 Return to FAQ Drug Therapies
We’ve posted a new FAQ and answer under Drug Therapies and Medicines in our section:
Are Anticoagulants and blood thinners the same thing? How do they thin the blood? Blood clots are usually good, such as when you get a scrape or cut.
Blood clots are usually good, such as when you get a scrape or cut.
Since A-Fib increases your risk of clots and stroke, blood thinners are prescribed to prevent or break up blood clots in your heart and blood vessels and thereby reduce your chance of an A-Fib-related stroke.
Although referred to as “blood thinners”, they don’t actually affect the “thickness” of your blood.
There are two main types: anticoagulants and antiplatelet agents. They work differently to accomplish the same end effect.
Anticoagulants work chemically to lengthen the time it takes to form a blood clot.
Common anticoagulants include warfarin (Coumadin), Heparin and the NOACs such as apixaban (Eliquis).
Antiplatelets prevent blood cells (platelets) from clumping together to form a clot.
Common antiplatelet medications include aspirin, ticlopidine (Ticlid) and clopidogrel (Plavix) .
Final answer: Yes, an anticoagulant is a blood thinner, but not all blood thinners are anticoagulants.
Note: To read about ‘clot buster’ drugs or treatments that could save you from a debilitating stroke, see my article: Your Nearest ‘Certified Stroke Center’ Could Save Your Life.
Warfarin has one, but the NOACs don’t. What am I talking about?
Warfarin (Coumadin) has a way to monitor and measure its effectiveness for a specific patient. But there’s no similar way to measure the effectiveness of the new Novel Anticoagulant drugs (NOACs).
Warfarin and Your INR
With warfarin, blood testing for your INR (International Normalized Ratio) will tell your doctor what dosage of warfarin is needed to maintain your ideal INR range between 2.0 and 3.0. (Below 2.0, there’s more of a risk of an ischemic [clotting] stroke; above 4.0, there’s more of a risk of a hemorrhagic [bleeding] stroke.)
NOACs: No Blood Testing but at What Price?
From the clinical trials we know NOACs work as well as warfarin. In addition, the NOACs don’t require periodic blood testing. But the FDA, under pressure for new anticoagulants, approved the NOACs without there being any established or universally recognized method of determining their clot preventing effectiveness.
Without any method of determining their clot preventing effectiveness, how can you determine if your NOAC is working for you? … Continue reading this report…->
Taking almost any prescription medication has trade-offs.
In the case of anticoagulants, on the one hand you get protection from having an A-Fib stroke (which often leads to death or severe disability), but on the other hand you have an increased risk of bleeding. That’s how they work. Therefore blood thinners are inherently dangerous. “Oral anticoagulants are high-risk medications” as stated by Drs. Witt and Hanseen of the University of Utah College of Pharmacy.
As an A-Fib patient, whether or not to be on anticoagulant or not, and which one, is one of the most difficult decisions you and your doctor must make.
Your Risk of Life-Long Anticoagulation Therapy
With the 2014 Guidelines for Management of Patients with Atrial Fibrillation, came significant changes to the rating scale doctors use to assess your risk of stroke. The guidelines call for many more people to be on a lifetime of anticoagulant therapy.
An anticoagulant should not be prescribed as a precaution, but only when a significant risk of stroke exists.
But taking an anticoagulant isn’t like taking a daily vitamin. An anticoagulant should not be prescribed as a precaution, but only when a significant risk of stroke exists.
Long term, we know the blood thinner warfarin (Coumadin) is associated with microbleeds, hemorrhagic stroke, and developing early dementia. What about the newer NOACs? There’s little long-term risk data, but we expect similar long-term risks.
Was 10 years of Anticoagulant Use the Cause of this Patient’s Dementia?
Dr. John Day, in an editorial in The Journal of Innovations in Cardiac Rhythm Management, described his patient, Bob, who had been on anticoagulation therapy for 10 years (even though he had had a successful catheter ablation and was A-Fib free).
“Could the drug therapy be the cause of this case of dementia? – Dr. John Day”
Bob was suffering from early dementia. A cranial MRI revealed … Continue reading this report…->
The controversy began with the publication of the 2014 Guidelines for Management of Patients with Atrial Fibrillation (A-Fib). The joint HRS/ACC/AHA committee report included significant changes to the rating scale used by doctors to assess an A-Fib patient’s risk of stroke (The rating scale now used is the CHA2DS2-VASc).
Magically, simply because of her gender, a woman is automatically given one point on the stroke risk scale no matter how healthy she is otherwise.
Yes, you read that correctly.
Just because of gender, ALL women automatically have one strike against them when assessing their risk of A-Fib-related stroke.
All it takes is one additional point, say for having hypertension, and the Guidelines call for life-long anticoagulant drug therapy. (It doesn’t seems to matter if your hypertension is under control with meds.) A score of 2 or higher (out of 10) = lifelong anticoagulation therapy!