Warfarin Withdrawal in Patient’s Awaiting Surgery Increases the Risk for Stroke

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Last April Dr. Adnan I. Qureshi reported on research, at the 67th Annual Meeting of the American Academy of Neurology, that has shown that atrial fibrillation patient’s who are taken off of warfarin for surgical procedures have an increased likelihood of having a stroke.

Subjects included in the analysis had atrial fibrillation plus at least one additional risk factor for stroke or death: age >65 years, systemic hypertension, diabetes, congestive heart failure, transient ischemic attack, prior stroke, left atrium diameter 50+ mm, left ventricular fractional shortening <25%, or left ventricular ejection fraction <40%.

Specifically atrial fibrillation patients who discontinued warfarin for surgical procedures had a 1.1% rate of stroke while atrial fibrillation patients who remained on warfarin had a 0.2% rate of stroke.

Read more here:

Warfarin withdrawal in atrial fibrillation patients awaiting surgery dramatically ups stroke risk

Well, this seems like one of those articles where you read the headline and think, “Duh!” Like the article about how obese children have a higher chance of hypertension – No kidding?

Obviously if you are on a medication, in this case warfarin, to prevent having a stroke, and you stop taking the medication, well, you have an increase likelihood of having a stroke. I think everybody suspected this – but what we see here is that the rate of stroke increases five-fold. Wow – that seems incredible!

This article reinforces my strong belief that strict compliance with taking my medications, especially warfarin, is a good idea!

As far as surgery is concerned, clearly, if you need to have the surgery and you need to go off the warfarin, then so be it. The article didn’t mention anything about bridging with Lovenox. You might want to ask your surgeon about that. And also – consider how important the surgery is to your general health. Is the surgery truly necessary? Is it worth risking a stroke?

La Muerte Tocando Guitarra

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Emergency Pack for Trail Running or Mountain Biking While on Anticoagulants (Coumadin, Xarelto, Pradaxa, Plavix)

This article is a work in progress and is only a description of my strategy for the time being. I hope to learn from readers of this blog about how to better plan for a trail debacle.

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Heading out for a trail run on the Pacific Crest Trail

What kinds of things should a person like me, who is dealing with atrial fibrillation and is taking an anticoagulant (I take Pradaxa), carry on a long run in the wilderness? Or during a long mountain bike ride in remote areas?

When the high country in our local wildernesses is not covered with snow, I will generally do runs, nearly every weekend, of anywhere between six to twenty miles. I almost always run alone (except for my trail buddy – Ringo).

Dangerous and a bad idea? Possibly. But this is what I enjoy in life so I don’t plan on stopping any time soon.

The most important piece of equipment is a phone. People complain that everybody is always on their smartphone, and they should NOT be talking on their phones on mountain summits when everybody else is trying to get all Zen-like and self-actualized, and whatever – that’s a different discussion. You certainly don’t even need to have your phone on; but you absolutely should take it with you, and it should be fully charged. The days of getting hopelessly lost and spelling out SOS with rocks hoping a search plane will find you are fading into the past. A smartphone is a GPS and a direct link to help.

I always carry my iPhone in a baggie with my ID and a sheet of paper towel (which I use for unrelated toilet purposes).

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Fully charged and protected from water

Even if there is poor cell phone coverage in your local high mountain or deep canyon wilderness, and a phone call isn’t always possible, I find that a text message can often still be sent. It might take a while but it eventually will be sent, especially if I am moving along a trail.

There is the standard emergency gear that most people take, often called the “ten essentials” which most people carry while in the wilderness. Of course there is truly no such thing as a standard ten essentials and the list of things you carry will vary depending on the season, your skill set, your location, and your past experience.

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My generic survival gear

I got out my little survival kit that I typically carry in the wilderness, and of course not everything is pictured here, and I might not even have all of this stuff with me on any given trip. Naturally I will also have other things like food, gels, electrolytes, a jacket, and plenty of water.

What I found in my default wilderness pack is:

Two knives – a mini-leatherman tool and a standard knife. I will only actually carry one of these.

Two lights – a headlamp and a tiny LED flashlight (one is plenty).

Fire starter – a cigarette lighter, birthday candles, a tampon, and hand sanitizer (which I discovered has completely evaporated).

A space blanket, a compass.

Repair gear (Shoe laces, tenacious tape, dental floss)

Pain pills: Vicoprofen samples – okay they expired in 2000 but I’m guessing they are still good (at least for a placebo effect). Missing: Benadryl for allergies or yellow jacket stings, and I probably should have some of my Pradaxa in case I end up unexpectedly staying out overnight. Also missing: small roll of duct tape, safety pins, and my whistle!

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Saint Christopher Medal

Oh, and there is a Saint Christopher medal. This one belonged to my grandfather. Well it probably won’t change anything, but it certainly couldn’t hurt. Feel free to substitute your own personal good luck charm.

But what about specific items for the runner on an anticoagulant? Is there anything else beyond the “ten essentials”?

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Other stuff: Map with reading glasses (if needed) and some rope

Obviously having a major bleed while running alone in the wilderness would be a disaster. Death is certainly a possibility. How can a trail runner prepare to increase the odds of a good outcome?

I always make sure to let somebody know (usually my wife) where I’m going and I also send her a text (I text “OOTW” short for “out of the woods”) when I get back to my vehicle.

I also wear a Road ID. This way if somebody finds me they will know I am on an anticoagulant. Maybe this won’t help, but it certainly is worth wearing. At least they will be able to figure out why I bled out so quickly (I know – not funny).

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My Road ID

Another item I always carry is a bandanna. This can be used for a number of purposes, such as making a field dressing; but I want to have it in case I need a tourniquet. Plus – I have an extra one because my trail dog always has one draped around his neck.

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Bandanna

My bandanna came in handy a week ago when my wife Margo (not on an anticoagulant) crashed her mountain bike and punctured her left thigh with her brake lever. I used it to make a compressive dressing before we road our bikes back to where we could get a ride to the hospital.

One item I do not currently have but definitely need to obtain is a Quickclot field dressing. Evidently these things really work and are routinely used in combat situations. It is a topical coagulant (an anti-anti-coagulant?) which helps clot blood and also serves as a physical barrier to bleeding. I’ve been meaning to obtain one of these for a long time. They are available online via amazon.com, and I just ordered one.

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Quickclot

Question: Will the Quickclot sponge even work on bleeding in an individual who is on a direct thrombin inhibitor like Pradaxa? Answer: I have no idea. I’ll let you know if I ever get a chance to find out.

In case of bleeding the most important first step is to apply direct pressure. As a surgeon I have a lot of experience with this. Usually sixty seconds of direct thumb pressure will stop or slow most bleeding, but of course if you take an anticoagulant it will take longer. Apply direct pressure as long as necessary. Elevate the wound if possible. Don’t try to clean out major wounds as this will restart bleeding – that can be done later at the hospital.

A tourniquet is a last resort, but the bandanna can be used as a compressive dressing if needed.

Please understand that an anticoagulant doesn’t completely stop clotting of blood, it just makes it take longer. Eventually bleeding will stop. Hopefully before all the blood leaves your body!

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Ringo always has a spare bandanna for me

Bonus – How to stop a nosebleed:

I have been plagued by frequent nosebleeds since I was a child but, oddly enough, I haven’t had a single nosebleed since I started Pradaxa a couple of years ago. The best method I have found is to pinch the nose, fairly tightly, just above the nostrils, and lean forward. Don’t lie with your head back – that doesn’t work. Hold for a full sixty seconds. Repeat as necessary.

If you are, like me, a trail runner or mountain biker on an anticoagulant, I would love to hear from you. Please leave comments and suggestions in the comments area below.

Thanks.

Atrial Fibrillation News Update

Here are a few internet news stories related to atrial fibrillation. In the future I’ll try to update more frequently so I don’t end up with four topics in one blog entry.

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Overall, the increase in risk of heart attack was about 70% in AF patients, even after accounting for other cardiovascular disease risk factors, such as hypertension, high cholesterol, body mass index, and history of stroke and vascular disease. However, when the researchers looked at subgroups, they found that increased risk of heart attack was more than doubled in women and African Americans with AF—but less than 50% for men and whites with AF.

I’m not sure what to say about this – hopefully runners with atrial fibrillation (who hopefully also have other heart healthy lifestyle choices – like a healthy diet, not smoking, reasonable body weight) will do better than the general population. One bit of good news – the blood thinners a fib patients take to prevent stroke also seem to help prevent heart attacks.

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“Novel” anticoagulants refers to the newer prescription anticoagulants that are used as an alternative to Coumadin (warfarin). Specifically: Pradaxa (which is the one I currently take), Xarelto, and Eliquis.

I can tell you that as a clinician there are not many things more frustrating than prescribing medications for people who are on Coumadin – it seems like it interacts with everything! One of the great things about the newer anticoagulants is that they have less drug interactions – but they still do have potential drug interactions.

Please click on the link to see tables for drug interactions involving Pradaxa (Dabigatran), Xarelto (Rivaroxaban), and Eliquis (Apixaban).

Obviously all of the novel anticoagulants can interact with any other drug that is *ALSO* an anticoagulant – like Plavix or aspirin. Keep in mind that this includes NSAIDs like Alleve (naproxen), Motrin (ibuprofen), etc.

Personally, I completely avoid taking ibuprofen and naproxen – but every once in a while (like after a brutal long run) I will take a Celebrex. Tylenol (Acetaminophen) is fine – no interactions with the anticoagulants (although it has its own issues).

By the way – if you read the article and see a possible drug interaction please don’t stop taking any of your meds – but contact your own doctor immediately for advice.

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A recent study has shown that Coumadin (warfarin) actually increases the risk of stroke for people in atrial fibrillation during the FIRST THIRTY DAYS of warfarin therapy. That’s just the first thirty days – the idea is to prevent having a stroke, and that’s what taking Coumadin does.

This finding does not suggest that anything will change – doctors are still going to put people on warfarin to prevent stroke. They just have to get through the first thirty days!

If you are on warfarin and you read this article – please do not stop taking your medication.

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Finally – the FDA has not yet approved the Watchman left atrial appendage closure device by Boston Scientific – but it has given a “vote of confidence.” It appears that this gadget, which is implanted in the left atrium to prevent the formation of the clots that cause strokes, may be approved by the FDA for the US market late this year. The majority of the panel agreed that the Watchman was equivalent to standard treatment with warfarin, but it hasn’t been compared to the new novel anticoagulants (see above).

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Atrial Fibrillation Stroke Calculator

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Atrial Fibrillation Stroke Calculator

I saw this link today on Facebook and thought I would share it – it is an AF Stroke Risk Calculator, and was posted by the Atrial Fibrillation Association – a great resource for people with atrial fibrillation. As you probably know one of the greatest risks of being afflicted with atrial fibrillation is that it can lead to you having a stroke. Blood clots can form in the malfunctioning atrium, break loose, travel to the brain and – BOOM!!!! – you’ve had a stroke. Prevention is the best approach.

This calculator is basically a clever automated version of the CHADS2 score. I was delighted to find my risk is 0%.

But if course my risk is definitely higher than zero percent – even if my CHADS2 score is zero.

My heart is abnormal in more ways than the atrial fibrillation. I have hypertrophy of my left ventricle (from running – not a risk factor) but I also have “severe hypertrophy” of my left atrium (the top chamber of the heart) which my cardiologist assures me is a risk factor for stroke and although my CHADS2 remains zero I am on an anticoagulant (Pradaxa).

My question has been: Why not include left atrial hypertrophy in the CHADS2 calculation?

Answer: I dunno.

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Lillian and Lolawanda ready for another trail run

My other question has been: What else can I do to reduce my risk of a stroke?

I understand my risk is NOT zero, regardless of what this calculator says.

Obviously one thing I know I can do is to remember to take my Pradaxa twice daily. Believe me, for somebody who is only taking one medication it isn’t as easy to remember as you might think. I have considered switching to Xarelto simply because of the once a day dosing.

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My Pradaxa

But other than that what else can I do? One more thing (I think) – stay well hydrated.

As a large, slow, long distance runner (who is often on the trail for several hours at a time) I sweat more than smaller runners, and I have to be very careful not to become dehydrated. I spoke with a friend of mine who is an Internists/hospitalist and he agreed – don’t become dehydrated. Being dehydrated can literally thicken the blood and increase the chance on a clot, and therefore increase the chance of a stroke.

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Be Careful Out There!

How much water should a person drink? I have no specific prescription but what I do is try to drink enough so that my urine is relatively clear once per day. Also there is such a thing as too much water and big, middle-aged distance runners are at relatively high risk of hyponatremia (too much water – not enough sodium) so be careful out there!

We talked about other risk factors are there? Risk factors for blood clots in the legs include being inactive, obesity, and smoking – probably less likely for the readers of this blog.

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Sedentary after a LONG RUN

What about alcohol? Does that increase the risk? He said probably not and in moderation might even decrease the risk – but remember – alcohol clearly increases your risk of atrial fibrillation – and if you drink enough alcohol you will become dehydrated – so there you go!

By the way – don’t expect this this risk calculator or this blog to advise you as to whether or not you should take your aspirin, your warfarin (Coumadin), your Xarelto, or your Pradaxa. It is important that you make this decision with your doctor.

Mountain Biking and Atrial Fibrillation

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Mountain Biking in Oregon – Waldo Lake Trail

I’ve just returned from a nearly three-hour long mountain bike ride, so I thought it would be a good time to write about mountain biking while in persistent atrial fibrillation (this discussion is pertaining specifically to persistent A fib meaning I am always in atrial fibrillation and don’t ever expect to NOT be in a fib; I think people who have episodes of paroxysmal atrial fibrillation are going to have a different result).

One of my main concerns when I was first verified to have persistent atrial fibrillation was whether or not would be able to continue mountain biking. I started road riding in the early 80s, back when I still lived in the Midwest. When I moved to Klamath Falls, Oregon in 1987 I began mountain biking. This is a great place to ride, and we have a terrific trail system at Moore Park, as well as a couple of local high mountain singletrack trails that are legal for mountain biking (Brown Mountain Trail, Rye Spur Trail). I feel real connection to these trails and have been riding some of them for over twenty-five years.

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Rye Spur Trail, Klamath County, Oregon

I didn’t use to run is much as I do now, and back in the late 80s and early 90s I would pretty much mountain bike five or six days per week. I have developed some good bike handling skills, especially since in the early days there was no front or rear suspension, and nobody really knew what they were doing anyway. We pretty much plunged our quick release seat posts down into the frame, switched to granny gear as soon as we hit dirt, and would (inappropriately) lock up our back wheels and skid down steep hills – very much discouraged in this modern era. But that’s the way it was – skills develop over time.

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One of my old mountain bikes

At any rate I have developed good skills – skills specific to these particular trails, seeing that I generally know every rock and anticipate every little drop off.

There are two issues with mountain biking and atrial fibrillation. The first, obviously, is that my cardiac output is reduced by about 15 or 20%, so naturally I am a little bit slower. People get slower when they get older, too, so there’s that to deal with as well. But the real issue, I think, is the fact that I am on a potent anticoagulant – Pradaxa. One of the disadvantages of Pradaxa is that it works really well (but the real disadvantages that it does not have a reversal agent). Clearly – there is a risk of bleeding associated with crashing your mountain bike on the trail.

I sort of doubt whether Coumadin is that much safer than Pradaxa as far as this is concerned – while it is true that there is a reversal agent for Coumadin, what is the likelihood that, if I had a major crash, I would be able to get to the emergency department in time for them to give me the reversal agent? I generally ride alone, and our trails are pretty remote. It would take a while for me to get out of there, especially if I was bleeding all over the place, or even worse, if I were bleeding into the space previously occupied by important parts of my brain.

Over the years my skills have improved and my style has changed quite a bit. At age 53 I’m no longer much of a daredevil (I never really was). Back when I was thirty and was riding about five days per week, I estimated that I had one minor crash per week, and usually one major crash per season. In all that time I think I’ve only actually hit my head once (I definitely recall a bleeding ear after crashing on a technical descent on a trail called Garbage – never liked that trail).

I have always felt that all of your instincts and reflexes are directed toward protecting the head. It’s automatic.

Of course I have worn a helmet when bicycling since 1983. I even bought a new helmet when I went into atrial fibrillation and started anticoagulation. It fits better than my old one and it’s florescent green, so hopefully I have less chance of being run over by a pickup truck.

The only time I have ever had a significant bleeding problem while mountain biking was back in 1990. I came off the trail ride and was heading around the paved road at Moore Park to the picnic area to get some water when some young guys in a pickup shouted at me, “Wrong way, dude!” I didn’t yell back at them, but I turned around and glared at them as I zipped down a little hill to the picnic area, giving them a look that said, “You talkin’ to me?” I was going pretty fast at that point and hit a speed bump that sent me skidding across the pavement for a while.

I bet those guys were impressed.

Anyway, I had a lot of road rash, was just goes with bicycling to a certain extent, but the worst thing was I had a “degloving injury” on the side of my abdomen. What that means is that part of my skin more or less stuck to the pavement while the rest of me kept moving and the skin was pulled away from the underlying tissue. It didn’t break all the way through the skin, but I developed a hematoma the size of a baseball right where the “love handle” would normally be. Twenty-three years later it’s actually still there to a certain extent, not the blood, but a big lump of scar tissue beneath the skin, and the skin over that area is still kind of numb.

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Klamath Ridgeview Trail – Moore Park

That happened with no anticoagulation – I never even took an aspirin back then. If I had a similar injury now that would’ve been a major hematoma – I might even need a transfusion.

That’s the risk. Falls are part of riding a mountain bike. I’ve been on Pradaxa for a year now and I think I’ve only had two crashes. I am so much more cautious than I used to be that I rarely ever crash, and when I do crash it usually something stupid like having mud or ice in my pedals and not been able to click out when stopping, falling over like Artie Johnson used to do on that tricycle on Rowan and Martin’s Laugh In. I honestly can’t say that I’ve noticed more bruising or bleeding than I would expect prior to Pradaxa. So far, so good.

I feel it is important, however, that when you’re cardiologist tells you that you probably shouldn’t be mountain biking that you do what he says. Don’t be like me. Don’t disregard your cardiologist advice. Do as I say, not as I do.

All joking aside – there is a certain risk and if you can accept that level of risk, then continue mountain biking. If not, stay off the trails.

As far as how much persistent atrial fibrillation affects my climbing, well, when I first get started it is quite difficult. After I warm up it really doesn’t seem like it’s any different than not be in atrial fibrillation. Recall that I do not take anything like a beta blocker or an antiarrhythmic – if you take medications like that your experience may definitely be different. All I take is the anticoagulant.

I’m slow, definitely slower than I was twenty-five years ago, but it almost seems like it’s within the realm of what you’d expect from being that much older. Like I said in the article about running in atrial fibrillation, it’s almost like you’re a pickup truck with a four speed manual transmission, but you can only use second and third gear. But you can still have a lot of fun in those two gears! It just takes a while to warm up.

Personally I think road biking is more dangerous than mountain biking, as far as bleeding risks are concerned. All my best crashes have been on pavement, including my best mountain bike crashes (see above). And pavement is usually where cars, driven by people who are talking or texting on smart-phones, hit you.

As far as endurance and energy output are concerned road biking, by its very nature, is easier to do in persistent atrial fibrillation that mountain biking. On a road bike you get into a groove, and have a certain steady energy output. That’s perfect for atrial fibrillation. Anybody who trail rides, especially on technical, steep trails, can tell you that mountain biking consists of a little burst of energy here, then a little short, brief period of rest and recovery here (by slow pedaling for a couple of seconds), and then hammering the pedals again to get over the next little obstacle, or whatever. That’s what’s fun about it – it’s almost like doing a puzzle. Trail riding involves a lot of little, short, anaerobic bursts of energy – and of course atrial fibrillation has diminished this ability, as far as I’m concerned.

Although, speaking strictly of endurance, I don’t think that is changed too much since I went into persistent atrial fibrillation. I can still ride for just as long as I used to be able to ride. I have found that while I have lost speed with age I have gained endurance in spite of atrial fibrillation.

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Moore Park Mountain Bike Trails

I am very interested in other mountain bikers’ experiences with atrial fibrillation, especially athletes who take rate control or anti-arrhythmic medications. Please feel free to leave comments – Thanks!

Pradaxa and CHADS2

The only specific treatment I take with respect to my atrial fibrillation is a blood thinner. I am on Pradaxa which for me, I believe, is a better choice than no anticoagulation, aspirin, or Coumadin (warfarin).

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Some of my Pradaxa

One of the worst things that can happen to a person in atrial fibrillation is that blood clots can form in the atria (plural of atrial), and can then release and become lodged in the brain. Since the left atrium is not really beating, and in my case it is quite enlarged, blood tends to pool here and this is perfect conditions for forming a blood clot. When a blood clot becomes lodged in the brain that is called a stroke or a cerebral vascular accident (CVA) and should be avoided at all costs. I actually met two different people, in one week, that had had strokes secondary to atrial fibrillation, and both of them were in their 50s. Both of them, regrettably, were lackadaisical about taking their anticoagulant at the time of their CVAs. Having a stroke, if you survive it, is an extreme life-changing event – definitely something to be avoided if possible.

Some people do not take any blood thinner at all. If your CHADS2 score is zero this is an option. My CHADS2 score is technically zero, but because of my severe left atrial hypertrophy my doctors think it is best that I am anticoagulated, and I fully agree.

What is meant by a CHADS2 score? Here is a link that explains, quite well the CHADS2 score:

CHADS2 on Wikipedia

Basically you get one point each for having congestive heart failure (C), being hypertensive (high blood pressure) (H), being seventy-five years of age or over (A), being diabetic (D), and you get two points if you have had a previous history of a stroke (S2). And it even spells CHADS2!

So, for example, if you are a ninety-year-old diabetic with high blood pressure and congestive heart failure, and you have already had a stroke, your CHADS2 score is maxed out at six points. Yes, you should definitely be on a blood thinner.

If you are a forty year old non-diabetic, non-hypertensive cyclocross racer who has demonstrated episodes of atrial fibrillation, but have no other risk factors, then aspirin, or no anti-coagulation at all, could possibly be an option.

If you have atrial fibrillation is important that you discuss this with your doctor and listen to what he or she has to say. I’m not giving medical advice here, I’m just explaining the system.

If your CHADS2 score is one aspirin or an anticoagulant such as coumadin may be an appropriate choice. But if your CHADS2 score is one or more you may want to be an anticoagulant such as Coumadin, Pradaxa, or Xarelto. Again, is important that you discuss this and agree with your doctor.

There are four choices regarding anticoagulation, and the choices are 1.) no anticoagulation 2.) aspirin, 3.) Coumadin,  and 4.) The newer, more expensive, but more convenient anticoagulants such as Pradaxa, Xarelto, and Eliquis.

Coumadin is relatively inexpensive, but interacts with a lot of different medications as well as a lot of different foods. I am a vegetarian and I eat a lot of green leafy vegetables which would make Coumadin a difficult choice for me. Also when I previously took Coumadin for six months after my open heart surgery I was having migraine headaches nearly every day. I rarely have a migraine since I discontinued Coumadin nearly 20 years ago. I don’t take any other medications, but if you do take other medications there’s a good chance that Coumadin may interact with them as well. Coumadin also requires frequent blood tests in order to make sure your anticoagulated at the proper level. Pradaxa and Xarelto do not require any blood tests. The disadvantage, and this is a big disadvantage, is that Coumadin is reversible if you do develop a serious bleeding episode whereas Pradaxa and Xarelto, for all practical purposes are not. It is possible that Pradaxa and Xarelto may be reversible with dialysis; but how likely is that????

Pradaxa is taken twice daily, and Coumadin and Xarelto are once daily. My doctor put me on Pradaxa after I was shown to have persistent atrial fibrillation. I have been taking it for over a year and really have had no problems. I’ve crashed my mountain bike just a couple of times and really haven’t noticed much difference as far as bleeding or bruising is concerned. But these were low-impact crashes and I realize there are some real dangers associated with anti-coagulation. It is important that you discuss this choice with your own health care provider.

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By the way – I am fully aware that there are a zillion commercials for suing the “bad drug” Pradaxa – but I am convinced, that for me, my diet, and lifestyle, Pradaxa is safer than Coumadin.