FAQs A-Fib Ablations: Blood Thinner Post-Ablation? 

Catheter Ablation

Catheter Ablation

15. “After my successful Pulmonary Vein Ablation, do I still need to be on blood thinners like Coumadin or aspirin?”

You may still have a high CHADS2 stroke risk score or other factors that make it necessary for you to stay on blood thinners.

But if you no longer have A-Fib, you are no longer in danger of having an A-Fib stroke. So, in most cases, you don’t need to be on blood thinners.

A recent observational study involving nearly 38,000 patients found that the stroke risk of patients who had a successful catheter ablation was similar to patients with no history of A-Fib. When you are in sinus rhythm, your stroke risk is basically the same as a normal heart-healthy person.

However, there is no medication or treatment that would absolutely guarantee one would never get a stroke, even for people in normal sinus rhythm.

[pullquote]“Anticoagulant treatment for people with A-Fib ranks as one of the highest-risk treatments in older Americans.
∼Thomas J. Moore, MD[/pullquote]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). As Dr. John Mandrola says, “And if there is no A-Fib, there is no benefit from anticoagulation.”

A study in 2010 indicates that anticoagulants, like warfarin, can be stopped 3-6 months after a successful Pulmonary Vein Ablation (Isolation).

Silent A-Fib May be Appear Post-Ablation

However, though feeling cured of your A-Fib, you may still be experiencing ‘silent A-Fib’ (A-Fib with no symptoms) which can be dangerous.

But doctors today are very good at spotting silent A-Fib and have a wide variety of monitoring devices (such as the Zio patch which you wear like a Band-Aid for two weeks). These monitoring devices would capture any silent A-Fib episodes you may have and alert your doctor that you may still need to be on anticoagulants. If you’re worried about being in silent A-Fib, ask your doctor for more extensive monitoring. Short episodes of silent A-Fib in general aren’t likely to cause a clot.

Danger of Taking Anticoagulants

[pullquote]No one should be on anticoagulants unless there is a real risk of stroke. Anticoagulants have their own risks and dangers.[/pullquote]Anticoagulants are not like taking vitamins (contrary to the impression given by the recent TV advertisements for the new anticoagulants, NOACs).

No one should be on anticoagulants unless there is a real risk of stroke. Anticoagulants have their own risks and dangers. No one wants to be on blood thinners like warfarin (Coumadin). You bruise easily, cuts take a long time to stop bleeding, you can’t participate in any contact sports or any activities like mountain climbing, bike riding, etc.

If taking the newer anticoagulants (NOACs) and you’re in an accident, you risk bleeding to death, because there is currently no practical way to reverse the anticlotting effect.

(Added October 26, 2015: The FDA granted “accelerated approval” to Praxbind®, a reversal agent (antidote) to Pradaxa®. Praxbind is given intravenously to patients who have uncontrolled bleeding or require emergency surgery.)

[pullquote]Even a low dose like a baby aspirin (81 mg) can cause bleeding and intestinal problems.[/pullquote]When taking anticoagulants, there is an increased risk of developing a hemorrhagic stroke and gastrointestinal bleeding. And anticoagulants often have other bad side effects, make one feel sick, and diminish one’s 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.”

Even a low dose like a baby aspirin (81 mg) can cause bleeding and intestinal problems.

Whether you should be on anticoagulants after a successful catheter ablation is a judgment call for you and your doctor.

August 2015 Update: Aspirin is No Longer Recommended as First-Line Therapy

Aspirin is no longer recommended as first-line therapy for Atrial Fibrillation patients according to the 2014 AHA/ACC/HRS Treatment Guidelines for Atrial Fibrillation. Though not a new finding, it should be noted that aspirin has been downgraded to class 2B drug.

A similar directive is included in the 2012 European ESC guidelines for the Management of Atrial Fibrillation: aspirin is not recommended as first-line therapy for patients with a CHA2DS2-VASc score of 1.

Aspirin is not appropriate for people who are at low risk of cardiovascular disease and stroke. For these people, the risks of gastrointestinal bleeding and hemorrhagic strokes outweigh any potential benefit.

Aspirin also causes stomach ulcers in 13% of those using it. And these ulcers usually develop without any warning symptoms. Many of these ulcers will cause a serious stomach bleed at some point. Also, taking low-dose aspirin on a regular basis more than doubles your risk of developing wet macular degeneration. On the positive side, people regularly taking low-dose aspirin have a significantly lower chance of getting cancer.

When is aspirin appropriate? Aspirin is recommended for “secondary” prevention of cardiovascular disease such as to prevent a reoccurrence of a stroke or heart attack.

[su_spoiler title=”References for this Article” icon=”plus-square-1″]• Bunch, J.T. et al. “Catheter ablation may reduce stroke risk in atrial fibrillation patients.” Cardiac Rhythm News, Thursday, 05 Sept 2013 14:15. http://www.cxvascular.com/crn-latest-news/cardiac-rhythm-news—latest-news/catheter-ablation-may-reduce-stroke-risk-in-atrial-fibrillation-patients

• Mandrola, John. Atrial Flutter–15 facts you may want to know. In AF Ablation, Atrial fibrillation. August 5, 2013.

• Themistoclakis S. et al. “The risk of thromboembolism and need for oral anticoagulation after successful atrial fibrillation ablation.” J Am Coll Cardiol. 2010 Feb 23;55(8):735-43. http://www.ncbi.nlm.nih.gov/pubmed/20170810?dopt=Abstract

• 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

• Navarrete, A. et al. “Ablation of atrial fibrillation at the time of cavotricuspid isthmus ablation in patients with atrial flutter without documented atrial fibrillation derives a better long-term benefit.” Journal of Cardiovascular Electrophysiology, July 19, 2010 (Epub ahead of print)

• 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. Circulation. published online March 28, 2014, 4.2.1. Antiplatelet Agents, p 29.doi: 10.1161/CIR.0000000000000041 Last accessed Nov 23, 2014.URL: From http://content.onlinejacc.org/article.aspx?articleid=1854230

• ESC Management of Atrial Fibrillation 2010 and Focused Update (2012): ESC Clinical Practice Guidelines. European Society of Cardiology URL: http://www.escardio.org/Guidelines-&-Education/Clinical-Practice-Guidelines/Atrial-Fibrillation-Management-of-2010-and-Focused-Update-2012

• Shallenberger, Frank. Does This Exciting New Research Mean I Have to Change My Advice About Taking Aspirin? Second Opinion. Vol. XXV, No 9, September 2015

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