The 2014 CHA2DS2-VASC Guidelines and the Risks of Life-Long Anticoagulation Therapy
A-Fib-Free After Catheter Ablation, Patient on Anticoagulation Therapy for 10 years Develops Cerebral Microbleeds and Associated Early Dementia.
By Steve S. Ryan, Updated March 2016
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. Of concern, these new guidelines call for many more people to be on anticoagulant therapy, particularly women.
Of concern, these new guidelines call for many more people to be on anticoagulant therapy, particularly women.
Bob was suffering from early dementia. A cranial MRI revealed many cerebral microbleeds, probably caused by taking anticoagulants for years. Both antiplatelet and anticoagulant therapy significantly increase the risk of cerebral microbleeds which are associated with dementia. These microbleeds are usually permanent and irreversible.
Dr. Day asked, “Could it be that this was an iatrogenic (caused by a doctor’s activity or therapy) case of dementia? Was his 10 years of anticoagulant use for atrial fibrillation the cause of his dementia?”
The New CHA2DS2-VASc Guidelines for Anticoagulation Therapy
Dr. Day discusses the new CHA2DS2-VASc guidelines for anticoagulation therapy. He points out that none of the major studies supporting the CHA2DS2-VASc guidelines have reported the accompanying cerebral microbleed risk. He also calls our attention to the reports from many centers that long-term stroke risk following catheter ablation is very low. Ablation may reduce the total arrhythmia burden or convert recurrences to more organized rhythms, such as an atrial tachycardia, with a lower stroke risk.
This effect of A-Fib ablation isn’t recognized in the latest guidelines.
So, the question is, ‘Why the risks of life-long anticoagulation therapy if the patient has had a successful ablation procedure?’
(See more research contradicting the 2014 Guides: A study using the Taiwan Research Database of 186,570 A-Fib patients, they discounted female gender and only looked at females with a CHA2DS2-VASc score of 2 (one additional risk factor besides being female).1,2,3
Warning: The Risks of Life-long Anticoagulation Therapy
Dr. Day concludes, “Somehow I think we have lost sight of the total picture with the new A-Fib management guidelines. In my mind, I am not convinced that the long-term stroke risk of a CHA2DS2-VASc score of 1 or 2 (depending on which risk factors are present) justifies all of the risks of life-long anticoagulation therapy, particularly if the patient has had a successful ablation procedure.”4 Dr. John Mandrola echoes Dr. Day, “And if there is no A-Fib, there is no benefit from anticoagulation.”5
“But CHA2D2-VASc are just guidelines, aren’t they? Doctors don’t have to follow them, do they?”
Unfortunately once guidelines like these become official, they in effect become the law of the land. If a doctor doesn’t follow them and a patient has a stroke, the doctor is almost guaranteed a losing malpractice law suit. The first thing a trial lawyer will point out to an arbitrator or jury is that the doctor didn’t follow current guidelines.
This puts doctors in a very difficult position. Even though Dr. Day knows all too well and agonizes over the fact that his anticoagulant therapy probably caused his patient Bob’s dementia, he can’t change the guidelines.
See also my articles: Women in A-Fib Not at Greater Risk of Stroke! and Israeli Study-Being Female Not a Risk Factor for Stroke.)
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Last updated: Tuesday, March 29, 2016
- Chao TF, et al. Should atrial fibrillation patients with 1 additional risk factor of the CHA2DS2-VASc score (beyond sex) receive oral anticoagulation? J Am Coll Cardiol. 2015 Feb 24;65(7):635-42. doi: 10.1016/j.jacc.2014.11.046. PubMed PMID: 25677422. http://www.ncbi.nlm.nih.gov/pubmed/25677422↵
- Amson, Yoav et al. Are There Gender-Related Differences In Management, And Outcome Of Patients With Atrial Fibrillation? A Prospective National Study. Arrhythmias and Clinical EP. Acc.15. JACC. March 17, 2015, Volume 65, Issue 10S. doi: 10.1016/S0735-1097(15)60469-7 http://content.onlinejacc.org/article.aspx?articleid=2198096&resultClick=3↵
- Friberg et al. Benefit of anticoagulation unlikely in patients with atrial fibrillation and a CHA2DS2-VASc score of 1. J AM Coll Cardiol. 2015; 65(3):a-232. URL: http://www.sciencedirect.com/science/article/pii/S0735109714070119. doi:10.1016/j.jacc.2014.10.052↵
- Day, John. Letter from the Editor in Chief. The Journal of Innovations in Cardiac Rhythm Management, 5 (2014), A6-A7. Last accessed May 15, 2014, URL: http://www.innovationsincrm.com/cardiac-rhythm-management/2014/may/586-letter-from-the-editor-in-chief↵
- 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↵