Doctors & patients are saying about 'A-Fib.com'...


"A-Fib.com is a great web site for patients, that is unequaled by anything else out there."

Dr. Douglas L. Packer, MD, FHRS, Mayo Clinic, Rochester, MN

"Jill and I put you and your work in our prayers every night. What you do to help people through this [A-Fib] process is really incredible."

Jill and Steve Douglas, East Troy, WI 

“I really appreciate all the information on your website as it allows me to be a better informed patient and to know what questions to ask my EP. 

Faye Spencer, Boise, ID, April 2017

“I think your site has helped a lot of patients.”

Dr. Hugh G. Calkins, MD  Johns Hopkins,
Baltimore, MD


Doctors & patients are saying about 'Beat Your A-Fib'...


"If I had [your book] 10 years ago, it would have saved me 8 years of hell.”

Roy Salmon, Patient, A-Fib Free,
Adelaide, Australia

"This book is incredibly complete and easy-to-understand for anybody. I certainly recommend it for patients who want to know more about atrial fibrillation than what they will learn from doctors...."

Pierre Jaïs, M.D. Professor of Cardiology, Haut-Lévêque Hospital, Bordeaux, France

"Dear Steve, I saw a patient this morning with your book [in hand] and highlights throughout. She loves it and finds it very useful to help her in dealing with atrial fibrillation."

Dr. Wilber Su,
Cavanaugh Heart Center, 
Phoenix, AZ

"...masterful. You managed to combine an encyclopedic compilation of information with the simplicity of presentation that enhances the delivery of the information to the reader. This is not an easy thing to do, but you have been very, very successful at it."

Ira David Levin, heart patient, 
Rome, Italy

"Within the pages of Beat Your A-Fib, Dr. Steve Ryan, PhD, provides a comprehensive guide for persons seeking to find a cure for their Atrial Fibrillation."

Walter Kerwin, MD, Cedars-Sinai Medical Center, Los Angeles, CA


Unsafe Interaction Between Pradaxa and Common Calcium Channel Blockers

An observational study published in 2020 found that people with A-Fib taking two common rate control calcium channel blockers along with the anticoagulant Pradaxa had higher bleeding rates (GI bleeding, minor bleeding, and minor GI bleeding).

The study was an analysis of the potential drug-drug interaction between verapamil or diltiazem and DOACs.

The term DOAC has replaced use of NOAC.

The study was conducted using US population-based data (2010-2015) analyzed between January 1 and July 15, 2019. Data were obtained on 48,442 patients with nonvalvular atrial fibrillation who had received an index prescription of dabigatran, rivaroxaban, or apixaban.

Analysis was restricted to individuals with no history of kidney disease who were receiving standard doses of the DOACs.

Drug-Drug Interactions Found When Co-Administered

Researchers found that taking the drugs Verapamil and Diltiazem (rate control calcium channel blockers) along with the anticoagulant Pradaxa had higher bleeding rates.

Other anticoagulants such as Xarelto and Eliquis didn’t cause more bleeding. (Apixaban [Eliquis] had consistently lower bleeding event rates among all DOACs.)

(For you technical types, Dabigatran functions as a P-glycoprotein inhibitor (P-gp), an important protein that pumps many foreign substances, such as toxins and drugs, out of cells. Verapamil and diltiazem are also P-gp inhibitors.)

Pradaxa Data Compiled and Compared to Four Calcium Channel Blockers

The investigators compiled data from IBM Watson MarketScan Databases.

Comparisons were made between 1,764 Pradaxa (dabigatran etexilate) users taking verapamil or diltiazem versus 3,105 Pradaxa users taking amlodipine (a calcium channel blocker used primarily to lower blood pressure which isn’t a P-gp inhibitor). The overall bleeding rate was 52% higher compared to amlodipine.

In addition, comparisons were made between 1,793 Pradaxa users taking verapamil or diltiazem versus 3,224 Pradaxa users on metoprolol (a beta-blocker which isn’t a P-gp inhibitor). The overall bleeding rate was 43% higher compared to metoprolol.

Avoid Mixing Pradaxa with Verapamil & Diltiazem

The message of this study is clear. “Clinicians and patients may need to consider alternative DOAC therapy other than dabigatran” when using P-gp inhibitors such as verapamil and diltiazem. (Amiodarone is another P-gp inhibitor.) “It is not safe to combine dabigatran (Pradaxa) with P-glycoprotein (P-gp) inhibitors in people with atrial fibrillation (Afib)” regardless of kidney function.

What This Means to Patients

If you are taking the anticoagulant Pradaxa, along with Verapamil and Diltiazem (rate control calcium channel blockers), talk to your doctor about changing to another DOAC (and take a copy of this article with you).

Happily, there are several DOACs, so there’s seldom an overwhelming need to continue on Pradaxa (dabigatran). Eliquis (apixaban), for example, tested the best and is the safest of the DOACs.

Resources for this article
• Lou, Nicole. An Unsafe Interaction Between Pradaxa and Common Meds―Study suggests drug-drug interaction regardless of kidney function. Medpage Today, April 24, 2020. https://www.medpagetoday.com/cardiology/prevention/86132

• Pham, P. et al. Association of oral anticoagulants and verapamil or diltiazem with adverse bleeding events in patients with nonvalvular atrial fibrillation and normal kidney function. JAMA Network Open, 2020; 3(4): e203593. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2764843

Book Review: “Restart Your Heart: The Playbook for Thriving with AFib” by Dr. Aseem Desai

Review by Steve S. Ryan, PhD

Restart Your Heart by Dr. Aseem Desai

Dr. Aseem Desai’s book Restart Your Heart: The Playbook for Thriving with AFib is written for Atrial Fibrillation patients by a practicing Electrophysiologist. It will be well received and is long overdue.

Caveat: By advocating living with A-Fib and by not telling patients of the dangers of living in A-Fib, Dr. Desai may be doing lasting harm to many A-Fib patients.

Dr. Desai’s Writing Style

One of the best features of Dr. Desai’s book is his patient-friendly writing style. He avoids “medicalize.” What he writes is easy to read and relatable. And he doesn’t shy away from explaining complicated concepts.

He is particularly good at explaining the scientific basis of A-Fib in a way patients can relate to. In particular, his explanation and illustration of Ion Channel Receptors (p. 21-23) is one of the best parts of his book.

A Dangerous and Deceptive Goal for A-Fib Patients

Atrial Fibrillation (A-Fib) is a progressive disease. The longer you have A-Fib, the greater the risk of your A-Fib episodes becoming more frequent and longer, often leading to continuous (Chronic) A-Fib. The abnormal rhythm in your heart causes changes and enlarges your atria (called remodeling), making it work harder over time.

Leaving patients in A-Fib overworks the heart, leads to fibrosis, stretches/expands the atrial heart walls, weakens the heart, increases the risk of  stroke, develops (congestive) heart failure, and leads to dementia because of reduced blood flow to the brain.

I cannot endorse Dr. Aseem Desai’s book because he encourages patients to live with A-Fib. He writes/advocates the following (location noted):
… Continue reading this book review..->

Gastroparesis: a Rare Complication After A-Fib Ablation

Gastroparesis is a condition in which your stomach empties into your small intestine more slowly than it should. It can be either temporary or chronic. Gastroparesis can occur after surgery or another medical procedure that interrupts your digestion.

Symptoms of Gastroparesis

When you have Gastroparesis, you feel bloated after eating, you may have stomach pain, or you may be vomiting. You may lose weight, your blood sugar levels may fluctuate, you may be dehydrated, your esophagus may be inflamed and you may experience malnutrition because your stomach isn’t absorbing nutrients.

Gastroparesis After Catheter Ablation

Gastroparesis is a rare complication of A-Fib ablation. It’s a condition that affects the stomach muscles and prevents proper stomach emptying. If after your catheter ablation, you experience any of the above symptoms, you may be experiencing Gastroparesis.

The cause can be damage to the vagal nerve which controls the stomach muscles. This can happen when ablation at the right inferior Pulmonary Vein (PV) affects the esophagus. The distance between the right inferior PV (RIPV) and the esophagus is an independent predictor of gastroparesis. … Continue reading this report…->

Are Women at Higher Risk of Dementia? A Rotterdam Observational Study

Background: The Rotterdam Study is a population-based study ongoing since 1990 in the city of Rotterdam in The Netherlands. It was a response to the changing demographics leading to an increase of elderly in most populations. Follow-up studies have been effective in finding causes of heart disease and cancer.

Dementia risk is increasing worldwide. An observational population-based study from Rotterdam found that there was a higher risk of dementia in Dutch women versus men (25.9% vs 13.7%). Rates of stroke were similar between women and men. The women had a higher lifetime risk of developing dementia (1 in 3 for women vs 1 in 5 for men).

Is Greater Life Expectancy a Factor?

One can’t help but wonder why these Dutch women had an increased risk of developing dementia as compared to risk of stroke.

The authors of this study speculated that this discrepancy may be due to the fact that women in the Rotterdam study had a higher life-expectancy than men (83.5 years vs 81.7 years for men).

“With longer life-expectancy, individuals (women) in this study simply had more time to develop (dementia) in a timeframe with high age-specific incidence rates.”

The authors also pointed out that the women in this study “were substantially lower educated compared to men, which may have led to a lower dementia resilience in women.”

Gender-Specific Interventions to Reduce Risk of Dementia

Unfortunately, there aren’t any medicines that can cure dementia or slow it down. But there are treatments to help ease some of its symptoms.

The good news: In high income countries, there is a declining number of people developing dementia. This may be due to preventive strategies such as better vascular risk factor management, improved educational attainment, and other public health developments that improve the resilience for dementia.

The authors recommend gender-specific interventions to help reduce the risk of dementia. For example, support for women suffering from loneliness and depression and dietary counseling for men.

Editor’s Comments
Editor's Comments about Cecelia's A-Fib story
Developing Dementia is Related to Aging Not Gender: This observational study does not imply that women are genetically inferior to men with regard to the risk of developing dementia. Developing dementia is related to aging, and women, in general, do live longer than men.
Loneliness and Depression Risk Factors for Dementia: I correspond with a woman with A-Fib who recently lost her husband. He died way too young. She is still devastated by the loss.
It happens all too often. Women out living their husband/life companion of many years.

Though a non-genetic factor, loneliness and depression certainly are risk factors for dementia. As a society we need to recognize what many older women experience and offer support.

Resources for this article
• Licher, S. et al. Lifetime risk of common neurological diseases in the elderly population. J Neurol Neurosung Psychiatry. 2019;90:148-156. https://jnnp.bmj.com/content/90/2/148 . doi: 10.1136/jnnp-2018-318650.

• Bunch, T. Jared. Cognitive Decline and Dementia in Patients with Atrial Fibrillation: Update on the CAF and PLUG Dementia Trials. EP Lab Digest. January 2020, vol. 20, no 1. P. 1.

How Long Does It Take for an A-Fib Clot to Form? The ASSERT Clinical Trial

Background: Of A-Fib stroke patients, 23% die and 44% suffer significant neurologic damage. This compares to only an 8% mortality rate from other causes of stroke.

How Long Does It Take for a Clot to Form? Some doctors say it only takes around 5 minutes for an A-Fib clot to form and cause a stroke that kills you.

This is generally not accepted thinking among Cardiologists and Electrophysiologists (EPs). The ASSERT clinical trial gives us some insights.

How Do Clots Form and Cause Strokes?

Clots aren’t formed instantaneously. It takes a while for blood to pool and form a clot of significant size. If you have a ten-minute attack of A-Fib, for example, it’s unlikely a clot/stroke will develop.

When someone is in A-Fib, blood is not being effectively pumped out of the left atrium. There are spots where blood can pool such in as the Left Atrial Appendage (LAA). This pooled blood can form a clot.

When the left atrium again beats normally, it can push this clot downstream into the left ventricle and into the bloodstream. From there, the clot can travel into the brain causing an ischemic (blocking) stroke.

Patients in permanent A-Fib are at higher risk of clots and stroke. But not in just a few minutes.

(Another risk of A-Fib is a hemorrhagic stroke when a blood vessel bursts, causing bleeding in the brain.)

ASSERT stands for “Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial”.

The ASSERT Study

The ASSERT clinical trial is a fascinating study with data collected by pacemakers and defibrillators (ICDs). Researchers looked at pacemaker patients and their risks of developing Silent A-Fib and stroke. Their primary question was: Do Pacemakers Prevent A-Fib?

A secondary benefit of the study is the A-Fib patient data collected. In particular, when and how long it takes for A-Fib patients to develop a serious risk of stroke.

The study gives us insight into when and how long it takes for A-Fib patients to develop a serious risk of stroke.

Study Description: The ASSERT study enrolled 2,580 patients, 65 years of age or older, with hypertension and no history of A-Fib, in whom a pacemaker or defibrillator (ICD) had recently been installed.

The pacemaker and ICD devices were programmed to detect silent A-Fib (i.e., Subclinical Atrial Tachycardia [SCAF]) when the heart rate reached 190 beats or more per minute lasting more than 6 minutes. The devices were checked at a clinical visit 3 months later. These patients were then followed up for around 2.5 years.

How Long in Silent A-Fib to Significantly Increase Clot/Stroke Risk

In the ASSERT study they found that it took more than 17.72 hours to significantly increase the annual stroke risk. The results of all patients are divided into four quartiles:

Duration Quartile: Time in Silent A-FibAnnual Stroke Risk
≥ 0.86 Hours1.23 %
0.87-3.63 Hours0 %
3.64-17.72 Hours1.18 %
˃ 17.72 Hours4.89 %

Researchers found the annual stroke risks are similar to the stroke risk for healthy people (which is considered to be 1%).

The ASSERT study basically said that it takes around 24 hours of silent A-Fib to develop a serious clot/risk of stroke (on average 3.1%).

Contrary Interpretation: In a later analysis of the same ASSERT study by Van Gelder (2017), patients with lengths of Subclinical Atrial Tachycardia (SCAF) from 6hrs to 24hrs were not significantly different from patients without SCAF.

Similar Trial Results: The TRENDS study, a prospective, observational study, also used implanted devices and found similar results as the ASSERT study.

Do Pacemakers Work to Prevent A-Fib?

The primary question of the ASSERT study was: Do Pacemakers Prevent A-Fib?
Finding: Pacemakers (continuous overdrive pacing) “does not prevent clinical atrial fibrillation.”

Editor’s Comments

Editor's Comments about Cecelia's A-Fib storyShorter Episodes of A-Fib Not Generally Dangerous: Despite studies such and ASSERT and TRENDS, we still need many more studies on how long it takes for a clot/stroke to form. Probably the most useful data to date does come from the ASSERT study where it took around 24 hours of silent A-Fib before clot/stroke risk was significantly increased.
People with shorter episodes of A-Fib or silent A-Fib, such as may occur after a successful catheter ablation, may not need to be on anticoagulants at all. Remember that anticoagulants are high risk drugs that shouldn’t be taken unless there is a real risk of stroke.

The general consensus is that A-Fib clots/strokes take around 24 hours to develop. In a popular article in Bottom Line Health, Dr. Antonio Gotto, cardiovascular disease specialist at Weill Cornell Medical College in New York City, says it takes one day for a clot to form.

Resources for this article

• Healey, J.S. et al. Subclinical Atrial Fibrillation and the Risk of Stroke. The New England Journal of Medicine 2012; 366:120-129. http://www.nejm.org/doi/full/10.1056/NEJMoa1105575?viewType=Print&viewClass=Print# DOI: 10.1056/NEJMoa1105575

• Glotzer, T. V. et al. The Relationship Between Daily Atrial Tachyarrhythmia Burden From Implantable Device Diagnostics and Stroke Risk―The TRENDS Study. Circulation: Arrhythmia and Electrophysiology, August 4, 2009. 2009;2:474-480. https://www.ncbi.nlm.nih.gov/pubmed/19843914 doi: 10.1161/CIRCEP.109.849638

• Gotto, Jr., Antonio M. Bottom Line Health, Vol 26, November 2012, p. 4.

• Van Gelder, I.C. et al. Duration of device-detected subclinical atrial fibrillation and occurrence of stroke in ASSERT. European Heart Journal, Volume 38, Issue 17. 1 May 2017, Pages 1339-1344, https://academic.oup.com/eurheartj/article/38/17/1339/3059370. doi.org/10.1093/eurheartj/ehx042

Post Surgery―Develops A-Fib, Drug Therapy & Supplements Restore Sinus Rhythm

My name is Richard, male, and born in 1945. I am 5′ 9’’, weigh 167 lbs., and am a non-smoker. My exercise is walking about 1.5 miles a day, and I have a healthy diet.

Complications from an Appendectomy Surgery―Develops A-Fib

In April 2018 I was in the hospital for three weeks. I had two surgeries, first an appendectomy and 10 days later correction of a problem caused by the first surgery.

After the second surgery I developed A-Fib, with no prior history of it.

Surgery is a form of trauma, and this shock depletes magnesium and can lead to heart arrhythmias.

The only drug to bring me back to sinus rhythm was Amiodarone. I left the hospital with prescriptions for Amiodarone 100 mg a day and Metoprolol Tartrate 25 mg twice a day.

Amiodarone Damages Thyroid

Everything was under control for several months. Until I had blood work that revealed my Thyroid was not functioning. Amiodarone was removed, and… continue reading Richard’s personal A-Fib story.

Our A-Fib Positive Thought/Prayer Group: Coordinator Needed

At A-Fib.com we believe in healing through hope, belief, prayer—and in the power of positive thoughts. To support our A-Fib.com readers in seeking their cure (or best outcome), we offer the assistance of our dedicated A-Fib Positive Thought/Prayer Group. This support group is just an email away.

Once we receive your request for prayer or positive thoughts, we ask our group of volunteers to support you as requested.

I consider this work a call from God and a special vocation.

My First-Hand Experience with our Positive Thoughts/Prayer Group

Instead of just writing about this phenomenon, I experienced it myself when I asked the group for positive thoughts & prayers for the success of my upcoming intestinal surgery on March 28, 2018.

So may people emailed me such heartfelt support it brought tears to my eyes. It was very encouraging to know I wasn’t alone, that so many cared about me. Can’t thank you all enough! (BTW: My surgery was successful.)

Many Thanks to Our Coordinator

For years, Barbara Cogburn has coordinated our A-Fib Positive Thought/Prayer Group, but has recently stepped down. We can’t thank her enough for this service to others with A-Fib.

Think of how many people Barbara has helped over the years, who have benefited from her warm, understanding emails and encouragement.

We Need a New Coordinator

Could you take on the coordinator role of our Positive Thought/Prayer Group?

You can have a direct impact in the lives of other A-Fib patients and their families.

How it Works: A-Fib patients would email you with their requests. You would respond with encouragement and assurance of the group’s support. Then you’d email their request to our group of volunteers.

For the details of what’s involved, with questions, etc., contact me at ssryan@a-fib.com.

ADVENT Trial of Pulsed Field Ablation (PFA) for Paroxysmal A-Fib! PFA a True Game Changer

Fundamentally different from traditional methods for cardiac ablation, I expect the FARAPULSE Pulsed Field Ablation (PFA) will change the way catheter ablations are done and will become an innovative and most effective treatment option for Atrial Fibrillation.

U.S. Trial of Pulsed Field Ablation (PFA)

The U.S. trial of the FARAPULSE Pulsed Field Ablation (PFA) system is underway. The first patients in the ADVENT Trial were treated at New York’s Mount Sinai Hospital by Vivek Reddy, M.D., Director of Cardiac Arrhythmia Services.

” I believe PFA will define a new era in the ablation of AF and possibly other arrhythmias.” – Dr. Pierre Jais, French Bordeaux LIRYC

The ADVENT Trial is a prospective randomized pivotal trial of the FARAPULSE Pulsed Field Ablation System compared with standard of care ablation in patients with paroxysmal atrial fibrillation.

“…We look forward to how our study can move adoption of this procedure forward,” said Dr. Vivek Y. Reddy.

ADVENT Trial is Recruiting: You May Quality

There are 37 study locations participating in the ADVENT Trial (see the list). Recruiting is underway and you may qualify.

Key inclusion criteria: Patients are required to meet all the following inclusion criteria to participate in this study (there are also exclusion criteria):

• Age 18-75
• Paroxysmal atrial fibrillation
• Anti-arrhythmic drug failed for efficacy or intolerance

Learn more about the ADVENT Trial on the FARAPULSE website. Prospective patients of The ADVENT Trial should contact their physician.

How PFA Works

As an emerging technology, there are many concepts and treatment strategies that will be brand new to you (they were for me).

Pulsed Field Ablation (PFA) is fundamentally different from traditional methods for cardiac ablation. PFA is very tissue selective.

PFA is Tissue Selective; Green labels are Preserved tissue; Red label is Ablated tissue

Through a process called irreversible electroporation, cardiac tissue targeted for ablation is rendered electrically inactive while collateral tissues are spared.

Unlike traditional thermal methods, PFA works on the selected cell types while leaving others alone.

Based on European clinical trials, these electric fields have proven very effective in durably “silencing” abnormal heart signals, while reducing the risk of damage to other nearby tissues.

For more on how PFA works, see my report: 2020 AF Symposium Pulsed Field Ablation—Emerging Tech for Atrial Fibrillation.

First Approved in Europe

In March 2021, Pulsed Field Ablation (PFA) from FARAPULSE, Inc. received CE Mark approval and can now market in the Europeans Union and other CE Mark countries. FARAPULSE plans to launch by first partnering with a select number of physicians, then move to a broader rollout.

Boston Scientific has expanded investment in FARAPULSE, Inc. and secured an exclusive option to acquire it.

Resources for this article
• Reddy VY, et ak. Pulsed Field Ablation of Paroxysmal Atrial Fibrillation: 1-Year Outcomes of IMPULSE, PEFCAT, and PEFCAT II. JACC Clin Electrophysiol. 2021 May;7(5):614-627. doi: 10.1016/j.jacep.2021.02.014. Epub 2021 Apr 28. PMID: 33933412.

• First AF Patients Treated With Farapulse Pulsed Field Ablation System. DAIC.com  MARCH 03, 2021. May-June 2021 Issue. https://www.dicardiology.com/content/first-af-patients-treated-farapulse-pulsed-field-ablation-system

• The FARAPULSE ADVENT PIVOTAL Trial (ADVENT). ClinicalTrial.gov https://www.clinicaltrials.gov/ct2/show/NCT04612244?term=NCT04612244&draw=2&rank=1

Editorial: Elderly With A-Fib and Dementia Still Given Blood Thinners

In a disturbing article about our elderly living in nursing homes, a third of older patients with A-Fib and severe dementia were still given anticoagulants during the last 6 months of their lives. This is according to analysis of patients Medicare data.

According to study authors, Dr. Gregory Ouellet of Yale University and his colleagues, “We were surprised that patients with markers of very high short-term mortality—for example, difficulty swallowing and weight loss—were more likely to be receiving anticoagulants…This is counterintuitive since the potential benefits of these medications are the lowest in this group.”

“These findings underscore the fact that, while practice guidelines contain a well-defined threshold for starting anticoagulation for AF, there is no clear standard for stopping it,” Dr. Ouellet and colleagues wrote in their article.

Dr. Ouellet unexpectedly found that greater bleeding risk (their ATRIA score) was also associated with greater odds of anticoagulant use. The greater their risk of bleeding, the more likely these elderly A-Fib patients were to be on anticoagulants.

Improper use of anticoagulants can cause intracranial hemorrhage, bruising and excessive bleeding.

Nursing home length of stay was more strongly associated with anticoagulant use instead of the patients’ stroke risk (CHA2DS2-VASc score).

In their study, Ouellet and co-authors used Medicare data to evaluate 15,217 nursing home residents with atrial fibrillation and advanced dementia who had at least moderate stroke risk (CHA2DS2-VASc score of 2 or more) and who died from 2014 through 2017.

That Makes No Sense! Is This the Way We Treat Our Elderly?

I was astounded to read this analysis found the greater their risk of bleeding, the more likely these elderly A-Fib patients were to be on anticoagulants. This improper use of anticoagulants can cause intracranial hemorrhage, bruising and excessive bleeding.

Nursing home patients with greater risk of bleeding should not be prescribed anticoagulants, but they were.

What this finding says is that many the nursing homes weren’t all that concerned about actual stroke risk when prescribing anticoagulants.

The most important treatment for elderly patients with severe dementia and limited life expectance is, as much as possible, to help their quality of life, to let them die in peace and as much comfort as possible. … Continue reading this book review..->

Comparing the Effectiveness and Safety of the Direct Oral Anticoagulants (DOACs) in Patients With A-Fib

Anticoagulants are used with high-risk Atrial Fibrillation patients for the prevention of clots and stroke. FDA approved in 2010, Direct Oral Anticoagulant (DOACs) quickly became attractive alternatives to warfarin, the long‐standing standard of care in anticoagulation.

DOACs include dabigatran (Pradaxa), rivaroxaban (Xarelto) and apixaban (Eliquis). (Edoxaban [Savaysa] approval came later.)

The use of the term “Direct Oral Anticoagulants” (DOACs) has replaced the term NOACs (Novel Oral Anticoagulants), but it means the same.

When the FDA approved DOACs (Direct Oral Anticoagulants), they relied on 3 different clinical trials. But these trials only compared a DOAC, like Eliquis, to warfarin, not to the other DOACs.

Someone like myself had to dig deep into the research to find evidence of which DOAC actually tested better/safer of the three. (I found that Eliquis tested better and was safer.)

For more about the DOACs, see my articles: Warfarin and the New Anticoagulants, and my report from the AF Symposium: The New Anticoagulants.

DOACs: Finally a Head-to-Head Comparison

Today there is clinical data comparing the DOACs against each other. (And support my original reports.)

A comprehensive review of 36 randomized control trials and observational studies included over 1 ¼ million patients. The DOACs compared were apixaban, dabigatran, rivaroxaban, and edoxaban. The reviewers found:

▪ For major bleeding: Eliquis (apixaban) “tended to be safer” than Xarelto (rivaroxaban) and Pradaxa (dabigatran) based on both direct and indirect comparisons;

▪ For best treatment: Eliquis had a higher probability of being the best treatment of decreased risk of stroke/systemic embolism;

▪ Highest benefit: Eliquis had the highest net clinical benefit and smallest NNTnet (Number Needed to Treat for net effect, i.e., how many people were helped by it, how many were harmed.)

Reviewers Conclusions

The researchers wrote: “Apixaban (Eliquis) appeared to have a favorable effectiveness-safety profile compared with the other DOACs (NOACs) in AF for stroke prevention, based on evidence from both direct and indirect comparisons.” (Translation: Eliquis was found to be more effective and safer than the other DOACs).

Editor’s Comments:

Editor's Comments about Cecelia's A-Fib storyIn the world of scientific statistics and cautious conclusions, this is about as big an endorsement as you will find: Eliquis is superior to the other anticoagulants.
If you’re on a different DOAC, talk to your doctor about switching to Eliquis.
Know the Risks of Taking Anticoagulants (Blood Thinners): Taking almost any prescription medication has trade-offs. In the case of anticoagulants, on 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 and other problems.
Is an Anticoagulant Necessary for Me? Be certain you should be on an anticoagulant in the first place. Doctors assess an A-Fib patient’s risk of stroke using a rating scale (called CHA2DS2-VASc). Ask your doctor what’s your risk-of-stroke score. If your score is a 1 or 2 (out of 10), ask if you could take a non-prescription approach to a blood thinner.
Remember Anticoagulants Are High Risk Drugs: Be aware that all anticoagulants are considered high risk drugs.

They aren’t like taking vitamins, though they are certainly better than having an A-Fib (ischemic) stroke. To learn more see: Anticoagulants Increase Risk of Hemorrhagic-Type Strokes.

Resource for this article
Zhang, J., et al. Comparative effectiveness and safety of direct acting oral anticoagulants in nonvalvular atrial fibrillation for stroke prevention: a systematic review and meta-analysis. Eur J Epidemiol (2021). https://doi.org/10.1007/s10654-021-00751-7

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