Don’t Want to Take Anticoagulants? Three Alternatives for A-Fib Patients
With Atrial Fibrillation, you are 4–5 times more likely to have an A-Fib (ischemic) stroke. Taking an anticoagulant helps prevent an A-Fib stroke and may give you peace of mind.
The negative side is that all anticoagulants are high-risk medications and inherently dangerous. You bruise easily, cuts take a long time to stop bleeding. You can’t participate in any contact sports. Bleeding events are common complications. There is an increased risk of developing a hemorrhagic stroke and gastrointestinal bleeding. See Risks of Life-Long Anticoagulation.
(Most EPs are well aware of the risks of life-long anticoagulation.)
Don’t want to take anticoagulants? What’s the alternative? Remove the reason you need an anticoagulant!
Three Alternatives to Taking Anticoagulants
Anticoagulants are used with high-risk Atrial Fibrillation patients for the prevention of clots and stroke.
The best way to deal with the increased risk of stroke and side effects of anticoagulants is to no longer need them. Here are three options:

RF Catheter ablation
#1 Alternative: Get rid of your A-Fib.
As electrophysiologist (EP) and prolific blogger Dr. John Mandrola wrote: “…if there is no A-Fib, there is no benefit from anticoagulation.”
Action: Request a catheter ablation procedure. Today, you can have an ablation immediately (called ‘first-line therapy’). You don’t have to waste a year on failed drug therapies. See Catheter Ablation Reduces Stroke Risk Even for Higher Risk Patients

Placing Watchman in LAA
#2 Alternative: Close off your Left Atrial Appendage (LAA).
The Left Atrial Appendage is where 90%-95% of A-Fib clots originate. Closing off the LAA provides similar protection against having an A-Fib (ischemic) stroke as being on an anticoagulant.
Action: Request a Watchman device. The Watchman device is inserted to close off your LAA and keep clots from entering your blood stream. See Watchman Better Than Lifetime on Warfarin

Natural blood thinners
#3 Alternative: Consider non-prescription blood thinners
Perhaps you can benefit from an increase in natural blood thinners such as turmeric, ginger and vitamin E or, especially, the supplement Nattokinase.
Action: Ask your doctor about your CHA2DS2-VASc score (a stroke risk assessor). If your score is a 1 or 2 (out of 10), ask if you could take a non-prescription approach to a blood thinner. See FAQ: “Are natural blood thinners as good as prescription blood thinners?”
Bottom Line
Whether or not to take anticoagulants (and which one) is one of the most difficult decisions you and your doctor must make. To stop taking an anticoagulant, talk to your doctor about alternatives:
• Catheter ablation
• LAA closure (Watchman device)
• Non-prescription blood thinners
These options may help you to no longer need an anticoagulant. As Dr. John Mandrola wrote: “…if there is no A-Fib, there is no benefit from anticoagulation.”
As an A-Fib patient, don’t settle for a lifetime on anticoagulants or blood thinners. Remember: You must be your own best patient advocate.
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.
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:
In 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. Bleeding events are common complications of anticoogulants.
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.
Q&A: Can Catheter Ablation Be a First-Choice Option?
Q: “I was told that I can’t have a catheter ablation to fix my A-Fib until after at least a year of trying different medications. Is that right? I don’t want to live in A-Fib for a year. I’m very symptomatic. I hate being in A-Fib.”
A: Catheter Ablation Can Be a First-Choice Option. Current Guideline for the Management of Patients with Atrial Fibrillation say you don’t have to wait before getting a catheter ablation. You can have a catheter ablation right away as a first-choice option.
Here is the actual wording of the guidelines:
“The role of catheter ablation as first-line therapy, prior to a trial of a Class I or III antiarrhythmic agent, is an appropriate indication for catheter ablation of AF in patients with symptomatic paroxysmal or persistent AF.”
Guidelines Level of Confidence: Catheter Ablation has a Class IIa Level of Evidence (LOE) indication. This means the “weight of evidence” is in favor of this treatment as useful and effective. (To read more, see Catheter Ablation of AF as First-Line Therapy (p. e307.), in the 2017 HRS/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation.)
Drugs First? Your doctor may talk about first trying antiarrhythmic meds. This can waste valuable time as most “antiarrhythmic” drug therapies are only effective about 40% of the time, can have bad side effects, and often become less effective day by day. And, you will most likely still have A-Fib.
Catheter Ablation as a First Choice? If you want to skip the drug therapies, ask your doctor about catheter ablation. If your electrophysiologist won’t talk to you about catheter ablation, seek a second opinion (or change doctors).
As an A-Fib patient, know your rights and be assertive.
2021 AF Symposium: New Technologies and Drugs―Flecainide Inhaler by InCarda
2021 AF Symposium
New Technologies and Drugs―Flecainide Inhaler by InCarda Therapeutics

Jeremy Ruskin, MD
Dr. Jeremy Ruskin of Massachusetts General Hospital gave a 5-minute Spotlight Session talk on InCarda Therapeutics’ flecainide inhaler. InCarda is a privately held biopharmaceutical company in Newark, CA.
Dr. Ruskin described the InCarda inhaler which uses flecainide, a well-established antiarrhythmic agent.

Flecainide Inhaler from Carda Therapeutics
When a patient with recent onset A-Fib self-administers the breath-activated inhaler, it produces a flecainide-containing aerosol when the patient inhales. This results in a rapid absorption of flecainide via the lungs into the heart. An A-Fib attack can be terminated in as little as 8 minutes.
By contrast, if flecainide is taken as a pill-in-the-pocket, it often takes much longer for the pill to work (20-30 minutes).
Aside from the problems associated with flecainide, this inhaler is generally safe and well tolerated.
According to Dr. Ruskin, “Inhaled Flecainide has the potential to be a practical, cost effective option for rapid conversion of AF to sinus rhythm.”
Editor’s Comments
The InCarda flecainide inhaler is already in FDA Phase II trials. But it will probably still be a couple of years before it’s generally available to doctors and patients.
InCarda Inhaler Better Than Pill-In-The-Pocket: The InCarda flecainide inhaler is or will be a welcome addition to Pill-In-The-Pocket therapy where patients only take a drug when it’s needed, not all the time. Today’s antiarrhythmic drugs can have bad side effects and be poorly tolerated if taken all the time. Think of how liberating it would be to just use an inhaler to quickly get out of an A-Fib attack.
One wonders if the InCarda inhaler can be developed for anticoagulants as well. Anticoagulants are high risk drugs especially for older patients.
f you find any errors on this page, email us. Y Last updated: Monday, April 19, 2021
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2021 AF Symposium: ATTEST Trial—Catheter Ablation to Modify Progression of AF
2021 AF Symposium
ATTEST Trial: Catheter Ablation to Modify Progression of AF

Dr. Karl-Heinz Kuck
Dr. Karl-Heinz Kuck of the Asklepios Klinik St. Georg in Hamburg, Germany, gave a presentation on the findings from the ATTEST Trial. (He also spoke on this topic at the 2020 AF Symposium).
Patient Risk: Progressing from Paroxysmal to Persistent A-Fib
Dr. Kuck pointed out that within one year, 4% to 15% of paroxysmal A-Fib patients become persistent.
In addition: they are at a higher risk of dying, they have more risk of stroke, and it’s more difficult to restore them to normal sinus rhythm. (In the Rocket AF trial, the mortality rate of persistent A-Fib was triple that of paroxysmal patients.)
The ATTEST Trial: RF Ablation vs Antiarrhythmic Drugs
The ATTEST clinical trial included 255 paroxysmal patients in 36 different study locations. They were older than 60 years and had to have been in A-Fib for at least 2 years (mean age 68). They had failed up to 2 antiarrhythmic drugs (either rate or rhythm control).
Patients were randomized to two groups: radiofrequency ablation (RF) (128) or antiarrhythmic drugs (127). They were followed for 3 years (ending in 2018).
ATTEST Findings
Significant data about the progression of A-Fib was learned from this trial.
• At 3 years, the rate of persistent A-Fib or atrial tachycardia was lower (2.4% ) in the RF group vs the antiarrhythmic drug group (17.5%).
• The RF group was approximately 10 times less likely to develop persistent A-Fib compared to the antiarrhythmic drug group.
• For patients in the antiarrhythmic drug group, 20.6% progressed to persistent A-Fib or atrial tachycardia compared to only 2.2% in the RF group.
• Recurrences occurred in 49% of the ablation group vs. 84% in the drug group. Repeat ablations were done on 17.1% of the ablation group.
Dr. Kuck’s Conclusions
Early radiofrequency ablation was superior to antiarrhythmic drugs to delay the progression to persistent atrial fibrillation among patients with paroxysmal A-Fib.
Dr. Kuck’s advice: “Ablate as early as possible.”
Editor’s Comments
The EAST-AFNET 4 Trial: The ATTEST Trial findings dovetailed with results from the EAST-AFNET 4 Trial.

Dr Paulus Kirchhof
In another ’21 AF Symposium presentation, Dr. Paulus Kirchoff (Institute of Cardiovascular Sciences, U. of Birmingham, UK) reported that EAST-AFNET 4 trial findings supported early initiation of rhythm therapy in cases of recent onset A-Fib. (See 2021 AF Symposium: EAST-AFNET 4 Trial—Early Rhythm Control Therapy in AF)
Research by both Dr. Kuck and Dr. Kirchhof came to the same conclusion: “ablate as early as possible” and the need for “early initiation of rhythm therapy.”
Why Risk Progressing into Persistent A-Fib? There are so many bad things that can happen to you when left in A-Fib. As Dr. Kuck points out, you’re at a higher risk of dying, there’s more risk of stroke, it’s more difficult to restore you to normal sinus rhythm.
And we haven’t even talked about heart damage from fibrosis, the risk of electrical remodeling of the heart, and the all-too-real dangers of taking antiarrhythmic drugs over time.
And what about quality of life? Who wants to live in A-Fib? There are few medical procedures so transformative and life changing as going from A-Fib to normal sinus rhythm.
Don’t Leave Someone in A-Fib―Ablate as Early as Possible: Dr. Kuck’s (and Dr. Kirchhof’s) research answers once and for all whether or not A-Fib patients should be left in A-Fib, whether seriously symptomatic or not (e.g., leaving A-Fib patients on rate control drugs but still in A-Fib.)
These patients are 10 times more likely to progress to persistent A-Fib. That’s why today’s Management of A-Fib Treatment Guidelines lists catheter ablation as a first-line choice. That is, A-Fib patients have the option of going directly to a catheter ablation.
Time for a Second Opinion? I occasionally hear of Cardiologists who refuse to refer patients for a catheter ablation, who tell patients a catheter ablation is unproven and dangerous. Not true!
When you hear something like that, it’s time to get a second opinion and/or change doctors.
Know Your Rights—Be Assertive: Your doctor may try to talk you into first trying antiarrhythmic meds before offering you the option of a catheter ablation.
As an A-Fib patient, know your rights and be assertive. According to the Management of Atrial Fibrillation Treatment guidelines, you have a right to choose catheter ablation as your first choice.
If you find any errors on this page, email us. Y Last updated: Friday, April 16, 2021
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2021 AF Symposium Spotlight Session: Drug in Development from Acesion Pharma
2021 AF Symposium
Spotlight Session: Drug in Development from Acesion Pharma
At this year’s AF Symposium, there were 22 Spotlight Session talks 5 minutes long spread out over 3 days. Normally I don’t report on them in detail, since they usually aren’t currently available (and may never make it through development and regulatory hurdles into the marketplace). But here’d one that may be of interest to patients.

Dr. John Camm
Dr. John Camm of St. George’s Hospital in Oxford, UK discussed a drug in development from Acesion Pharma, a Danish biotech company.
This new drug (AP30663) is highly atrial specific and works as an SK channel inhibitor [to suppress A-Fib]. SK channel inhibitors are ion channels present in the heart which regulate the cardiac rhythm.
Acesion’s new drug is designed for IV cardioversion of A-Fib to normal sinus rhythm.
Editor’s Comments:
Just the fact that Acesion is working on a new antiarrhythmic drug is news in itself. It’s been years since any new antiarrhythmic drugs have come on the market. And the antiarrhythmic drugs currently available to patients leave a lot to be desired.
Plus, the Acesion drug being developed is highly atrial specific which is an important advantage over most other antiarrhythmics.
If you find any errors on this page, email us. Y Last updated: Monday, April 19, 2021
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