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The Controversy Continues: Women, Anticoagulants, CHA2DS2-VASc and Risk of Bleeding
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!
Really?
Note: These Guidelines aren’t really just “guidelines”. In effect, they become the law of the land. Doctors who don’t follow them can lose malpractice lawsuits and even their medical license.
Research Studies Challenge the 2014 Guidelines
A large Swedish retrospective study by Friberg challenges the 2014 A-Fib Guidelines. The study looked at 140,420 A-Fib patients with a CHA2DS2-VASc score of 1.
The annual stroke risk score for women was 0.1%-0.2%. (In plain language, 0.1% is miniscule. That’s 1/10th of one percent.) Men had an annual stroke risk of 0.5%-0.7%.
Translation: A 0.1%-0.2% risk of stroke for women does not support adding ‘Female gender’ as a factor on the CHA2DS2-VASc stroke risk assessment.
A 2012 study from Denmark (Amson) and 2015 studies in Taiwan (Chao) and Israel (Amson) have similar findings and conclusions. Taiwan researchers concluded:
“Not all risk factors in CHA2DS2-VASc score carry an equal risk.”
Dr. John Day, Intermountain Medical Center, in an editorial in The Journal of Innovations in Cardiac Rhythm Management, wrote:
“Somehow I think we have lost sight of the total picture with the new [2104] 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… .”
The Danger of Anticoagulants: Increased Bleeding
“The risks of life-long anticoagulation therapy” Dr. Day refers to is the very real danger of increased bleeding. Bleeding events are common complications of taking anticoagulants.
Taking an anticoagulant isn’t like taking a daily vitamin. For example, if you take too much Vitamin C, your body will expel the excess through your urine. No harm done.
An anticoagulant should not be prescribed as a precaution, but only when a significant risk of stroke exists.
Safer, Healthier Alternatives to Anticoagulants
Don’t worry. If you have A-Fib and need the protection of an anticoagulant (or blood thinner), there are alternatives.
The #1 Alternative: Get rid of your A-Fib.
Request a catheter ablation procedure. Today, you can have an ablation immediately (called ‘first-line therapy’ by your doctor). You don’t have to waste a year on failed drug therapy.
EP and prolific blogger, Dr. John Mandrola wrote: “…if there is no A-Fib, there is no benefit from anticoagulation.”
The #2 Alternative: Close off your Left Atrial Appendage (LAA).
The LAA is where 90%-95% of A-Fib clots originate. Request a Watchman device. The Watchman device is inserted to close off your LAA to keep clots from entering your blood stream.
What Patients Need to Know
Don’t be intimidated into a lifetime of meds
If on anticoagulants, start a conversation with your doctor (take along a copy of this article). Ask what is your CHA2DS2-VASc score.
• If female, don’t let your EP rate your stroke risk higher just because you are a women.
• If your CHA2DS2-VASc score is a 1 or 2, don’t be intimidated into taking anticoagulants or warfarin for the rest of your life.
• Ask about a Catheter Ablation or the Watchman to eliminate (or reduce) your need to take blood thinners.
Show your doctor the research studies and expert opinions cited in this article (click ‘Reference for this article).
Remember if taking anticoagulants:
The associated risk of bleeding may be more dangerous than your risk of stroke.
Further reading: see my articles Catheter Ablation Reduces Stroke Risk Even for Higher Risk Patients and Watchman Better Than Lifetime on Warfarin
Nielsen PB et al. Female sex is a risk modifier rather than a risk factor for stroke in atrial fibrillation: should we use a CHA2DS2-VA score rather than CHA2DS2-VASc? Circulation. 2018;137:832-840 http://circ.ahajournals.org/content/137/8/832. doi.org/10.1161/CIRCULATIONAHA.117.029081
