Warfarin Users: NOACs now First-line Therapy
The use of warfarin (Coumadin, Jantoven) to prevent clots is no longer recommended for most A-Fib patients. With a superior safety profile, NOACs (Novel Oral Anticoagulants) are now recommended as first-line therapy for suitable A-Fib patients. NOACs include dabigatran (Pradaxa), rivaroxaban (Xarelto), Apixaban (Eliquis) and edoxaban (Savaysa).
A-Fib treatment guidelines were updated in 2019 by the American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS).
The guidelines recommend that Coumadin no longer be used to treat A-Fib except for a limited, specific group of patients. Instead, guidelines strongly recommend using NOACs (DOACs).
“New scientific studies show that NOACs may be safer for patients because there is less risk of bleeding, and they may also be more effective at preventing blood clots than warfarin,” said Craig T. January, MD, PhD, FACC, co-chair of the focused update.
NOACs (or DOACs) Guidelines
The guidelines instead encourage the use of “novel [direct] oral anticoagulants” (NOACs or DOACs) which are better at preventing stroke and have fewer side effects. I’ve written about the NOACs several times:
…Eliquis (apixaban) tested the best and is the safest. But all NOACs are considered high risk drugs and should only be taken if there is a real risk of stroke. (Warfarin vs. Pradaxa and the Other New Anticoagulants)
For example, if you’ve been cured of A-Fib and are A-Fib free by a catheter ablation, you normally don’t have to take NOACs. You aren’t in danger of having an A-Fib stroke if you don’t have A-Fib. NOACs are not like taking vitamins. (Blood Thinners After Ablation)
High Cost of NOACs: Co-Pay Card and Patient Assistance Discounts
I know NOACs are much more expensive than Coumadin. And I understand if you and your doctor may choose to continue using Coumadin because of the high cost of a NOACs.
But don’t give up so fast. There are resources to save on prescription cost. For example, here are two resources on Eliquis to check:
• Drugs.com has a very informative page about the NOAC, Eliquis. For example, see Eliquis Prices, Coupons and Patient Assistance Programs
• Eliquis Customer Connect: Bristol-Myers Squibb offers an Eliquis Co-pay card and program which might work to reduce your cost. See ELIQUIS Costs, Savings and Support.
“Eliquis Co-pay Card: Eligible patients may pay no more than $10 per 30-day supply for up to 24 months with an annual savings of $3800; for additional information, contact the program at 855-354-7847.”
Other NOAC drug companies may have similar discount plans. We offer these links to help you get started:
• Pradaxa (dabigatran), see PRADAXA Savings & Support
• Xarelto (rivaroxaban), see Get Savings and Support for XARELTO
• Savaysa (edoxaban), see The SAVAYSA Savings Card
If you are 65 or older, you may qualify for Senior Discounts.
Talk to Your Doctor if You’re on Warfarin
If you’ve on warfarin (Coumadin, Jantoven) to prevent blood clots, you know that this powerful drug can save your life. But warfarin treatment is a careful balance, and certain factors can tip the balance, increasing the risk of bleeding.
If you are taking warfarin, talk to your doctor about the NOACs and whether you should change from warfarin.
Taking an anticoagulants (and which one) is one of the most difficult decisions you and your doctor must make.
Medical ID: If you’re on any blood thinner, it’s a good idea to carry some kind of medical ID. If you have an accident involving bleeding, EMTs can call ahead to the ER and get the staff ready to help you. To print your own I.D. see: Print a free Medical Alert I.D. Wallet Card
Copy of FAQs Coping with A-Fib: Pacemaker for Too Slow a Heart?
FAQs Coping with A-Fib: Pacemaker
“Now my doctor says I need a pacemaker, because my heart rate is too slow and because I’m developing pauses.
I’m an athlete with A-Fib and have a naturally slow heart rate. Since I developed A-Fib, I was put on atenolol (a beta blocker) which really slows down my heart rate. What should I do?”
Get a second opinion. It’s crazy to go through the risks and lifestyle disruptions of having a pacemaker implanted just to be able to continue taking atenolol.
Because you are an athlete, your heart rate is naturally slow. But it’s normal for you.
As long as you feel fine and aren’t fainting from lack of blood flow, don’t be talked into getting a pacemaker. A slow or even very slow heart rate usually doesn’t cause any harm. As for heart rates, “normal” is indeed a wide swath.
In the words of Dr. John Mandrola:
“Do not implant pacemakers in patients with nonsymptomatic bradycardia (slow heart rate).The same holds for pauses, though they are certainly of more concern than a slow heart rate. Nonsymptomatic slow heart rate or pauses don’t justify exposing patients to the risks of implanting a pacemaker.”
Do not implant pacemakers in patients with nonsymptomatic bradycardia. This includes the wide spectrum of sinus node dysfunction (SND), asymptomatic pauses in patients with permanent AF, and young patients with medication-induced bradycardia. Humans exhibit tremendous variation of heart rate, and impressively slow heart rates frequently cause patients no harm. As for heart rates, ”normal” is indeed a wide swath. Unlike the more sinister high-degree AV block, SND is not immediately fatal. In 2012, there exist many strategies for the treatment of arrhythmia that do not include exposing patients to the risks of implanting a permanent intravascular device.
Back to FAQs: Coping with Your A-Fib
Last updated: Wednesday, August 26, 2020
2020 AF Symposium Challenging Case: 75-Year-Old, A-Fib Increases, Develops Bradycardia, 12-sec Heart Pause
2020 AF Symposium: AF Management
Challenging Case: 75-Year-Old, A-Fib Increases, Develops Bradycardia, 12-sec Heart Pause
by Steve S. Ryan
One of the most interesting sessions at the AF Symposium is the “Challenging Cases in AF Management: Anticoagulation, Arrhythmic Drugs and Catheter Ablation for AF” where leading doctors discuss very frankly their most difficult cases that year.
While several cases were discussed, here I summarize just one case.

Dr Eric Prystowsky
Patient History: 75-Year-Old Female
Case presented by Dr. Eric Prystowsky, St. Vincent Hospital, Indianapolis, IN
Dr. Prystowsky described the case of a 75-year-old female with A-Fib of at least three years duration. Before she came to Dr. Prystowsky, she was on Sotalol 40 mg 2/d and aspirin.
She was doing fine until a few months before when her A-Fib attacks became more frequent and with a more rapid rate. She also developed bradycardia and had a 12-second pause in heart beat.
Pacemaker and Pericardial Effusion: She had a pacemaker installed (but not by Dr. Prystowsky). During the implanting of the pacemaker, she developed a pericardial effusion (bleeding from the heart into the pericardium sac). She was not on anticoagulants.
Two weeks after implanting the pacemaker, she felt lousy with recurring palpitations.
Treatment by Dr. Prystowsky
Flecainide added: Dr. Prystowsky put her on flecainide 100 mg 2/day. She had slightly elevated blood pressure. She was also on aspirin, metoprolol, and Atorvastatin (to lower blood pressure by treating high cholesterol and triglyceride levels).
The patient had repeatedly been offered a catheter ablation, but she declined each time.
Reset Pacemaker: The pacemaker was controlling her atrium 93% of the time. Her Ejection Fraction was 55%-60% (a good range).
Dr. Prystowsky reprogrammed her pacemaker to change her AV interval. He stopped the aspirin, and put her on apixaban (Eliquis) 5 mg 2/d. He ordered a stress echo test to check her heart.
She felt better for 5 days.
Moderate Pericardial Effusion; Medications Adjusted
The patient then developed a moderate (“significant”) pericardial effusion.
Dr. Prystowsky stopped the apixaban (probably the cause of the pericardial effusion). Because she still had some symptomatic episodes of A-Fib (although much better), he then increased the flecainide to 150 mg.
Contributing Role: Referring to the cause of the patient’s pericardial effusion, Dr. Prystowsky faced the fact that “I did it.”
She experienced bad side effects with the increased dosage of flecainide. He put her on 100 mg 3/day to reduce the side effects.
The patient had repeatedly been offered a catheter ablation, but she declined each time.
Minimizing Pacing; Medication Adjusted
The patient’s ventricular pacing produced a wide QRS which Dr. Prystowsky said “worried the hell out of me.” He tried to minimize the pacing she received.
A CT scan revealed that her pacemaker incisions were fine, and that she had no more pericardial effusion. He re-started apixaban. She felt great.
He wound up putting her on amiodarone 200 mg which she tolerated well (previously she didn’t react well to Sotalol).
Dr. Prystowsky’s Lament
He described what he called his “shpilkes” index (Yiddish for anxiousness). When he talks to his fellows, “If you go home and worry about your patient at midnight, you ought to re-think everything.”
One Year Later and Lesson Learned
A year later she came in complaining of palpitations. Her pacemaker revealed that she only had 2 minutes of A-Fib in six months. Dr. Prystowsky told her, “I can’t do better than that.”
Dr. Prystowsky told the attendees that he would never again put a woman of her age on flecainide 150 mg.
He wrote me that it’s been over a year, and the patient is doing great.
If you find any errors on this page, email us. Y Last updated: Saturday, May 2, 2020
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2020 AF Symposium Abstract: Combination Device to Both Electrically Isolate and Occlude the LAA
2020 AF Symposium Abstract
Combination Device to Both Electrically Isolate and Occlude the Left Atrial Appendage (LAA)
by Steve S. Ryan

Heart showing location of Left Atrial Appendage (LAA)
Researchers in this study described the Left Atrial Appendage (LAA) as the 5th Pulmonary Vein. It plays a similar role as the PVs in generating A-Fib signals, but is the source of many clots that lead to stroke. Currently implanting an LAA occlusion device is a stand-alone procedure.
How the AuriGen Combination Device Works
An abstract by AuriGen Medical described a study with dogs of a very innovative device which both closes off and electrically isolates the Left Atrial Appendage (LAA) in a one-shot procedure.
The AuriGen Ablation, Delivery and Occlusion System consists of an LAA implant which closes off the LAA with a PET (polyethylene terephthalate) membrane, and an RF Ablation System to circumferential ablate the ostium of the LAA with an RF electrical array. Once implanted, the catheter electrodes are removed through a self-closing access conduit, leaving the occluder in play.
On day 7, the dogs underwent surgery to open the chest (thoracotomy) and observed that the LAA occluder device hadn’t moved. This also indicated that the ablation may have resulted in permanent electrical isolation of the LAA.
Editor’s Comments:
One can’t help but admire how A-Fib researchers and device manufacturers are developing innovative devices to improve A-Fib patient treatment.
From a patient’s perspective, it’s important that doctors and researchers recognize the importance of the LAA as a source of A-Fib signals (potentials). It seems to me that all too many EPs either ignore or put a low priority on mapping and ablating the LAA. Whereas other EPs such as Dr. Andrea Natale, after ablating the PVs, then focus on the LAA before examining any other areas of the heart. They recognize that the LAA often plays a major role in triggering A-Fib signals
Brilliant Idea to Combine LAA Closure with Electrical Isolation: The AuriGen combination occluder/LAA ablation device probably won’t be used in simple, recent onset, paroxysmal A-Fib cases because just isolating the PVs is usually enough to return patients to normal sinus rhythm (NSR).
Instead, the AuriGen combination device would be very useful in more complex cases where patients have had A-Fib for longer periods or who are more at risk of developing LAA clots. The AuriGen device can both close off and isolate the LAA in one procedure.
Practical Use by EPs: It’s is a long way from being available for A-Fib patients.
When and if the AuriGen device becomes available for patients, in practice EPs will probably first do a PVI to isolate the PVs, then proceed to use the AuriGen combination device to close off and isolate the LAA in the same procedure.
This will increase the effectiveness of ablation particularly in cases of persistent A-Fib. And, more importantly for patients, both procedures can be done at the same time.
If you find any errors on this page, email us. Y Last updated: Wednesday, August 26, 2020
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