Guidelines for Afib Patients: Blood Thinner Medication, Less Aspirin

Better care for patients with atrial fibrillation (afib) is the goal of treatment guidelines for doctors, based on research and clinical evidence. An estimated 2.7 million people in the United States have atrial fibrillation — an irregular heart rate that can lead to blood clots, stroke, and heart failure — and could benefit from updates in their patient care.

Working together, several leading heart groups agreed on patient treatment guidelines and published their recommendations in December 2014 in the Journal of the American College of Cardiology.

Atrial Fibrillation Care: Changes to Expect

Four atrial fibrillation assessment and treatment changes patients can expect are:

  1. Improved blood-thinning drugs to prevent stroke-causing blood clots
  2. Less aspirin use
  3. More use of ablation, a procedure that burns or freezes a portion of the heart to restore normal heartbeat rhythm
  4. Better risk assessment using a new, more complex risk calculator

Safer Blood-Thinning Drugs to Prevent Stroke

Newer drug options prevent blood clots in patients with afib and are alternatives to the previous mainstay of treatment, warfarin (Coumadin, Jantoven). Warfarin carries a risk of bleeding in the brain, and patients must have frequent blood monitoring and stick to a restricted diet, which can be difficult. This is because warfarin interacts with vitamin K — found in leafy greens and other foods.

The newer medications are  Pradaxa (dabigatran), Xarelto (rivaroxaban), Eliquis (apixaban), and most recently Savaysa (edoxaban) — which work by preventing pooled blood in the heart from clotting. Unlike warfarin, the newer drugs are safer and easier for patients to use.

“Some of these agents have been shown to offer even more stroke prevention than what is possible with warfarin,” says cardiologist John D. Day, MD, of Intermountain Medical Center Heart Institute in Murray, Utah. Dr. Day reviewed the guidelines for the Heart Rhythm Society.

“In addition, all of the newer blood thinners show that the most feared bleeding risk, namely spontaneous bleeding in the brain, is much less than that of warfarin,” says Day, highlighting the patient safety advantages.

The new blood thinners do not interact with foods, a big advantage for patients because they won't have to restrict their diets.

“The only thing holding me back from switching more of my patients to these newer blood thinners is the cost," Day confides. "For too many of my patients the cost of these newer medications is prohibitively expensive.”

Less Aspirin, Less Bleeding for People With Atrial Fibrillation

One big change is the recommendation to use less aspirin. Aspirin is now not recommended for anticoagulation to prevent stroke in patients who have afib.

“Studies have shown that aspirin does very little to lower stroke risk in afib patients, while at the same time being associated with a bleeding risk as high as some of the newer anticoagulant agents,” says Hugh Calkins, MD, professor of medicine and director of the Cardiac Arrhythmia Service at Johns Hopkins Medicine in Baltimore.

“In the old days aspirin was considered important for stroke prevention. New knowledge and reanalysis of prior studies reveals that aspirin does little to nothing to reduce stroke risk in this setting,” notes Dr. Calkins.

Ablation by the Right Doc at the Right Facility

The procedure known as radio-frequency ablation stops abnormal electrical signals from forming in the heart, where they can cause the abnormal rhythm of afib.

Patients are having catheter ablation with increased frequency, says Calkins. “This is consistent with multiple studies and clinical experience, which have shown that catheter ablation is more effective than antiarrhythmic drug therapy,” he explains.

Patient health outcomes depend on getting the best surgeon and the best facility, according to Dr. Day. “If catheter ablations can be performed by experienced cardiologists at experienced centers, then the outcomes of ablation are generally superior to medical treatment of afib.”

“Unfortunately, the outcomes with catheter ablation just have not been nearly as good at the smaller community hospitals," he adds. "For catheter ablation of afib it is best to stick to the large, high-volume, experienced hospitals.”

Better Atrial Fibrillation Risk Assessment

The newer afib risk calculator is more complex than the older one, says Day. Previously, the health risks that counted were congestive heart failure, high blood pressure, age, diabetes, and stroke. In contrast, the new risk calculator uses all of these and other factors to more accurately predict patients' risks.

What the new afib risk calculator uses to help determine the best treatment options:

  • Congestive heart failure: 1 point
  • High blood pressure: 1 point
  • Age 75 or higher: 1 point
  • Diabetes: 1 point
  • Stroke or TIA (transient ischemic attack): 2 points
  • Vascular disease: 1 point
  • Age 65 or higher: 1 point
  • Being female: 1 point

If your score is two or higher, you need a potent blood thinner. “As you can see, if you are a woman and are 65 or older, then you automatically require a potent blood thinner,” says Day.

How to Lower Your Afib Risk

What can people do now to lower their risk?

“First, don’t acquire risk factors that cause stroke,” says cardiologist T. Jared Bunch, MD, a columnist at Everyday Health.

“The ones we can do something about are high blood pressure and diabetes. Lifestyle changes such as daily exercise, weight loss, and a whole-foods, plant-based diet can lower your risk of developing high blood pressure and diabetes significantly,” says Dr. Bunch. He directs heart rhythm research at Intermountain Medical Center Heart Institute, in Murray, Utah and was not involved in the afib guidelines revisions.

Getting good sleep also comes into the picture. Bunch says, “If a person snores, has daytime fatigue, or needs a daytime nap, they need to be screened for sleep apnea. Sleep apnea is a very common condition in our country and increases risk of high blood pressure, weight gain, atrial fibrillation, and metabolic syndrome.”

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