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?

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Runners with Atrial Fibrillation – Thinking About Having a Cardioversion? “Look Before You Shock”

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This is, so far, the most discouraging article about atrial fibrillation I have ever read:

Left Atrial Appendage Thrombus When Least Expected: Look Before You Shock, Evaluate Before You Ablate | EP Lab Digest

As a distance runner with atrial fibrillation, who never missed a single dose of my anti-coagulant, and who has already had a blood clot in my left atrial appendage, and has already had a “mini-stroke” – this one leaves me feeling a bit hopeless.

Feel free to read the article; but I will go over a few key points here. One of the dreaded consequences of atrial fibrillation is having a stroke. Because the top chambers of the heart, the atria (plural of atrium) are beating so fast that they are basically just sitting there vibrating, the blood pools and becomes sluggish, and is prone to forming blood clots. Combine this with an enlarged left atrium and the likelihood is even higher. The blood clot forms in a little corner of the heart called the “left atrial appendage” (LAA).

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That’s where I formed a clot. If the blood clot, or a piece of the clot, breaks off it can quickly travel to the brain, get caught and cut off the circulation to part of the brain. This is a type of stroke, and is a huge problem for people with atrial fibrillation.

There are people who like to refer to a stroke as a “brain attack” because that’s what it is – like a heart attack in the brain. And like heart attacks there are big ones and small ones. I had a small one (TIA – tangent ischemia episode) that fortunately only lasted a minute or so. A big stroke, of course, can be fatal.

Important point: if a person is in atrial fibrillation and has blood clot in the LAA, it might be very stable. It might be just sitting there, hanging out, because the atria isn’t doing any beating. Everything is pretty tranquil in there. But then the person has a cardioversion (shock to reset the beating heart) or an ablation and the atrium begins to beat again, the blood starts moving through more quickly – well – now there’s a problem. Now the clot can break loose and BLAM!! – you’ve had a stroke!

The problem: it’s difficult to tell whether or not a patient has a clot prior to having a procedure. A regular echocardiogram doesn’t even show a small clot; there’s not enough detail. The best way to determine if a clot is present is to do a transesophageal echocardiogram (TEE).

teeTransesophageal Echocardiogram

I’ve had three TEEs – it’s not fun – sort of like swallowing a telephone. Thankfully the last two that I had involved an anesthesiologist who put me to sleep for the procedure.

As far as I know it is fairly common to have a TEE prior to having an ablation procedure; but less common before a cardioversion (the shock!), especially for people who presumably have a low risk of a LAA blot clot – like people who are appropriately anti-coagulated, or people who have had atrial fibrillation for less that 48 hours.

In this article five interesting cases are reviewed.

Case #1 – a patient who was effectively anti-coagulated but turned out to have a LAA clot anyway (sounds familiar).

Case #2 – a patient who was actually more anti-coagulated than thought necessary, and was in atrial flutter for less than 48 hours, but turned out to have a LAA clot anyway.

Case #3 – an appropriately anti-coagulated person with a low risk of clot (CHADS2 score=1), but turned out to have a LAA clot anyway.

Cases #4 and #5 were high risk patients who would be expected to have a high risk of a clot. Case #5 actually had three clots in her heart – yikes!

How does all this apply to athletes with atrial fibrillation? Well, apparently healthy, athletic patients, who are appropriately anti-coagulated, and either undergoing a planned or emergency cardioversion, still have a certain risk of having a LAA clot and subsequent stroke.

Should everybody have a TEE before having a cardioversion? Probably not. TEE is expensive, unpleasant, and if anesthesia is involved it basically takes up an entire day out of your schedule. It might be a good idea to talk it over with your cardiologist, however.

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Happy Trails

What is the ACLS Approach to Atrial Fibrillation? (Advanced Cardiac Life Support)

A week or so ago I re-certified in ACLS – Advanced Cardiac Life Support. ACLS is a set of emergency clinical interventions for cardiac arrest, stroke, respiratory arrest, etc., which is basically a step above BLS (Basic Life Support – formerly known as CPR). ACLS certification, in my case anyway, is done through the American Heart Association, and is only open to health care providers: doctors, nurses, dentists, advanced practice providers like PAs and nurse practitioners, EMTs, respiratory therapists, pharmacists, and so on.

I thought I’d write about it in this blog so people might know what to expect as far as the type of treatment they might experience if they have an unstable episode of atrial fibrillation.

I’m in permanent atrial fibrillation, so when I’m in one of these classes I’m glad I’m not hooked up to an EKG – I don’t feel like getting medicated or shocked!

ACLS deals with various problems using algorithms, so let’s look at the “Tachycardia with a Pulse Algorithm” which would generally apply to acute atrial fibrillation.

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So basically we start with a person with a fast heart rate. Tachycardia is, by definition, a pulse over 100 beats per minute, but for ACLS purposes it generally means a pulse over 150 bpm. Obviously not all tachycardia (fast heart rate) is atrial fibrillation.

For this article I am not discussing the other types of tachycardia, even though they are in the algorithm. I assume most people reading this blog are dealing with atrial fibrillation.

The first step is to assess the patient, identify and treat any underlying cause, make sure the patient is breathing effectively, assist if necessary, and give the patient some oxygen.

Now the next step is very important – is the patient stable? Five things: 1.) Is the blood pressure too low? 2.) Is there altered mental status (confusion)? 3.) Is the patient going into shock? 4.) Chest pain? 5.) Heart failure?

Even though I am in atrial fibrillation, all the time, I don’t have any of these symptoms. But if the patient is unstable and have tachycardia, basically, they are going to be getting some electricity! That means synchronized cardioversion, and in the case of atrial fibrillation (see “narrow irregular”) that means 120-200 joules – that’s a big shock!

Check out this video of cardioversion for atrial fibrillation – yikes!

Notice that it says “consider sedation.” Sedation can be considered, but not if it interferes with getting the unstable patient shocked as soon as possible. If you go into unstable atrial fibrillation at a race expect that the sedation will likely be skipped and get ready to be ZAPPED.

Photo by Ted Friedman.

Photo by Ted Friedman.

This is for unstable tachycardia – that means the patient is in some sort of crisis that may eventually be life threatening.

For an episode of stable atrial fibrillation expect vagal maneuvers and a referral to a cardiologist. Vagal maneuvers include firm carotid sinus massage, coughing, gagging, valsalva maneuver (holding your breath and “bearing down”), and placing your face in ice water (snow also works). A lot of people with intermittent atrial fibrillation already know how to do this.

For a great article about her episode of unstable atrial fib see Run, Smile, Drink Water and Don’t Die – A Guest Post by JoAnna Brogdon.

I’d be very interested in anybody else’s experience with unstable atrial fibrillation and what type of treatment was administered. Please comment below. Thanks.

Run, Smile, Drink Water and Don’t Die – A Guest Post by JoAnna Brogdon

Once upon a time there was a girl that loved to run just for the fun of it. She woke up early one morning on a cold and rainy March morning, excited to run the Rock Creek River Gorge Trail Run at Prentice-Cooper State Forest, just outside Chattanooga, Tennessee. She had run this race before and was wowed by the gorgeous gorge views and challenging single track trails.

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She signed up for the 10.2 mile run but wasn’t feeling exactly right that morning. She couldn’t put her finger on it. She was just a little off but that wasn’t going to stop her! She bounced out of bed and decided to do the 6.5 mile option instead of the 10.2—a decision that turned out to be one of the best she ever made.

The start was a little fast. Everyone was ready to get moving on the chilly and very wet morning. Soon the 158 runners headed into the woods and formed a single line, slowing the pace which was a good thing. The trails were incredibly slippery with tons of thick mud after much rain that winter. One runner took a face plant when crossing the creek and came up with a big gash on his forehead and blood dripping down his face.

“Are you OK said the girl?”

“Yes, I am just happy to be out here,” he responded.

“Me, too!” she replied. There were smiles on everyone’s faces as they headed up steep hills and carefully focused on the each step.

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At the half way mark, she was feeling OK but a little more tired than usual. No problem she said to herself, just having an off day. It was time to focus on other things, talk to people, make some jokes and carry on. She found a guy wearing a shirt that said, “Idiot Runner’s Club – Run, Smile, Drink Water and Don’t Die.” This sounds like my kind of runner thought the girl! They chatted and laughed about how slow they were going but how happy they were to be there instead of sitting on a couch or still sleeping in bed. The mud was so thick that their shoes nearly got sucked off but happily they went up yet another hill.

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Even though she wasn’t moving very quickly, her heart was starting to race quite fast. She slowed down and was walking more than running. She put her hands in the air a few times feeling like it was getting a little hard to breathe. Just focus on the gorgeous trails and it will be over soon, she told herself.

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There is that Idiot Runner again. He caught up and they were passing each other back and forth. It was time for more chatting and laughter. Only a few more hills and it will be time to relax and enjoy the day. One final push, climbing up through the narrow Indian Rockhouse and the race is almost over.

It is only 6.5 miles, she thought why does this feel so hard? She had run 50Ks and didn’t feel this bad. There goes a female racer. She will have to see if she can catch her but just felt so tired and ready to stop. Then she heard the crowd and knew that the end was near. She pushed as hard as she could one final time to make it to the finish line—she did it! And then she decided to sit down for a minute, she really didn’t feel so good … and then there was darkness …

…what is that noise?

She was waking up and heard a loud noise – it was her heart pounding at an incredible rate and a bright light in the distance. Someone was saying something to her, if she could only get to the light. She woke and found herself inside the medic tent with two physicians by her side. Her legs were cramping with the worst pain she had ever felt. Where was she? What had just happened? What was her name? Which hospital did she want to go to? So many questions…

She was being placed in an ambulance and sent to the local hospital. She was in rapid rate Atrial Fibrillation and needed a Cardizem drip to get her rate down. They admitted her to the hospital and the nurse came by to explain what A Fib meant. She drew a nice picture for the girl.

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She learned that A fib occurs when one or both of the upper chambers of the heart – called the atria – don’t beat the way they should. This can cause blood to pool in the left atrium, where a blood clot can form. If that clot breaks away, it can travel to the brain, where it can cause a type of stroke called an ischemic stroke.

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Two and half days in the hospital she waited for the meds to convert her heart back to normal sinus rhythm. They placed a band on her wrist that said “fall risk” – they had no idea.

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The doctor decided the only way to get her heart back to normal rhythm was to cardioconvert using an electric shock. She was wheeled down to the operating area and what a surprise– she saw the two doctors that were at the race. One was a cardiologist and the other was an anesthesiologist for cardiology. They were chatting and laughing and encouraging her that it was all going to be OK. Her cardiologist was running late and it delayed the procedure. He was known for this as he always took time with his patients. Right as the doctor arrived; the nurse looked at the monitor and said wait—she converted on her own! We don’t need to shock her heart. The girl was happy and believed that it was actually going to be OK— maybe not happily ever after but OK. She smiled as she remembered the new friend she had just met on the trail…

“Run, Smile, Drink Water and Don’t Die.” Now those were words to live by.

The End.

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JoAnna Brogdon, forty-three years old, went into a fib several times since the race and was hospitalized twice. She has no underlying chronic conditions and the doctors are unable to tell her why she has had a fib. She believes the worst part of the condition was the emotional stress and not being able to exercise as she had in the past. She underwent a cardiac ablation recently and her heart has been beating normally since. She is hopeful that she has put a fib behind her at least for now and looks forward to running, traveling and feeling normal again. JoAnna wants to support those that struggle with a fib and may be contacted at joannabrogdon@hotmail.com.

Atrial Fibrillation and Performance

I was under the impression that atrial fibrillation had not actually affected my pace that much, and that my slowing down was primarily a consequence of normal aging. I am fifty-three years old now and certainly can’t run at the same pace that I was able to when I was forty. One of my friends, who is approximately the same age as me, and also an endurance athlete, says that “every year is like a dog year now as far as performance is concerned.” In other words, for every year you get older you get seven years slower.

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Every Year is Definitely a Dog Year for Ringo

I have always been a Clydesdale runner and at over 6’3″ in height I have spent the last ten years around 235 pounds. I decided when I went into persistent atrial fibrillation that it was finally time to lose the extra weight and have successfully kept my weight around 195 pounds for the past year primarily by means of a vegetarian/pretty much vegan diet. Conventional wisdom states that if you lose 10 pounds you get approximately 30 seconds per mile faster as far as your running pace is concerned. So I figured a 40 pound weight loss combined with persistent atrial fibrillation would mean more or less breaking even as far as pace is concerned.

I discovered that this is certainly not the case.

Last Fall I had a procedure called cardioversion, wherein the heart is zapped back into normal sinus rhythm, and I remained in sinus rhythm for thirty-three days before going back into persistent atrial fibrillation. My electrophysiologist thought it would be worthwhile to try cardioversion with a “one strike and you’re out” philosophy – in other words nobody really expected that I would stay in sinus rhythm, but it would be worth a try.

Video of a Man (not me) Being Cardioverted

It was during those thirty-three days that I realized that atrial fibrillation really does slow me down more than I had thought. Mountain bike rides that were taking me one hour and fifteen minutes in atrial fibrillation, where taking the fifty-five minutes in sinus rhythm – even though I did the exact same trails. I also found I was doing my training runs at a pace approximately 1 to 1 1/2 minutes per mile faster in sinus rhythm. This is a significant difference. When I finally went back into atrial fibrillation I had slowed down again.

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Running With A Fib Feels Like Running in a Foot of Snow

Being in sinus rhythm, by the way, was sort of uncomfortable for me. I am more or less asymptomatic when I am in atrial fibrillation as far as how I actually feel, but my sinus rhythm sucks. If I feel my pulse, while in atrial fibrillation, obviously, I can feel that it is irregular, but I don’t feel all that bad except that certain times – such as getting up to run across room to answer the phone, or right after I get done with a run. (More on that later.) But when I went into sinus rhythm I realized that my sinus rhythm really isn’t that great to begin with – I was having PVCs or PACs about every fifth or sixth beat, and these are noticeably uncomfortable.