Afib Master Class with Dr. Eric Prystowsky — Stroke Prevention
February 4, 2019
- Summary: Watch this complimentary Afib Master Class on stroke prevention featuring world-renowned electrophysiologist Eric N. Prystowsky, MD
- Reading time: 1 minute
Dr. Prystowsky shares his advice on how to manage stroke risk (with your doctor), as well as how to weigh the risk of stroke against other risks, like falling or bleeding. He also discusses stroke prevention devices and how to know whether they may be something to talk with your clinicians about.
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What Do You Have to Consider Regarding Stroke Prevention?
[00:10] There are three limbs to treatment for people with afib: rate control, rhythm control, and prevention of stroke. I’d like you to forget the first two for a moment because if you get the third one wrong, I don’t really care what you do with the first two.
[00:22] Without a doubt, the most important thing is to get the third one right, preventing a stroke. And, this is the one patients struggle with the most because their initial reaction is, “A blood thinner? You know Doc, when I, when I just breeze by a door, I cut my… Look at this. I get, I get bruises all over the place.”
[00:41] So, here’s the thing, the obvious downsides of anticoagulants are there. You see them all the time. I hit my hand; I got a bruise. I nicked myself; I had a cut, it bled a little longer. But, the protective effects of a stroke aren’t looked at unless you have a stroke and you didn’t get the protection, right?
[01:02] So, you always see the downside of blood thinners, and that’s absolutely the way it is. You’ve got to look past that and look at the upside, which is you didn’t get a stroke.
[01:14] So, you never know that though, right? Because a patient can say to you, “Well, how do you know it was the drug, Doc? Maybe I just was lucky, and I didn’t have to take blood thinners, and I wouldn’t have had a stroke anyway?”
[01:25] You’re right. You don’t know it’s protecting you until it’s not protecting you. Okay? And, do you want a stroke?
[01:32] So, here’s what happens. This is the longest part of my discussion in the office with a patient. I sometimes take 10 or 15 minutes just on this. But, I cheat a little bit because I was a part of a team a long time ago that put together afib videos that are available to anybody. And, one of the most important videos I put in there shows what can happen if you make a mistake. It shows a clot in the heart.
[01:56] And, I show it to patients on my iPad that I use in the office, and I say, “Just watch this.” And, I don’t say anything. And, what you see is a clot; you see the clot dislodge; you see the clot go out of the aorta, right up to the brain, and boom, a stroke takes place. And, I say to them, “I’m not here to scare you. I’m telling you why we worry about this issue.” And, it’s powerful.
[02:24] I’m just going to tell you, very few people turn down blood thinners after that. But, I don’t show that video until I’ve had a full discussion of blood thinners, and if they meet criteria.
[02:35] So, it’s not up to you to push anybody into a blood thinner. I think that’s the wrong thing to do. I think it’s up to you, as the doctor, to be as open as you can in your discussion about risks and benefits of blood thinners. What is the actual risk to this patient? What is your CHA2DS2-VASc score? What is your actual risk of bleeding?
[02:55] But, I think it’s important, at that point, to also show them why we’re concerned. And, that’s why I show the video. It’s not to scare them. It’s to say, this is not some abstract theory. Here’s what we’re actually worried about. These are data that had been proved; this is not made up stuff. And, then I let the patient decide, with me, which way to go.
[03:15] The hardest decisions are people who are in that mid zone, we call it CHA2DS2-VASc of one. There, the patient could have almost the same, you know, stroke risk as a bleeding risk, and it’s hard to figure that out. So, honestly, I just tell them the following, after we’ve had a thorough discussion, they’re often not sure. They always say to me, “What would you do Dr. Prystowsky?” And, you know, I’m happy to tell them that, but you know, I’d rather them come to a decision on their own.
[03:43] And, I just say, “Well, let me explain this to you a little differently. If the risks are about the same, would you rather have a bleed, or would you rather have a stroke? I know you don’t want either, but what would be more important to you because the risks are about the same.”
[03:57] And, looked at that way, most people say, “Whoa, I never thought of it that way.” I say, “Well, that’s how you have to look at it this way because I can’t tell you you’re going to have a better outcome versus not in that category of risk.”
[04:11] And, usually, they’ll side with a blood thinner. Strokes scare all of us, and certainly patients. And, once you have a stroke, game’s over, or it’s usually over.
[04:21] So, honestly, I do everything I can to avoid strokes in my patients. It’s the first thing I talk about, and it’s the last thing I do before they leave.
How Do You Weigh Fall Risk Versus Stroke Risk?
[00:11] One of the toughest decisions patients and doctors have to make is the issue of a person falling and hitting their head and getting an intracranial bleed, for example, versus preventing a stroke. And, as people age, and they get more frail, and their abilities to not fall down are not as good, this issue rises up.
[00:34] My approach is pretty hardcore. I do everything I can, if someone’s at high risk for stroke, to find out exactly what their fall risk is.
[00:44] Often, when you dig into it, you’ll realize they never fell and hit their head. They’ve been unsteady of gait a couple of times; once or twice, they tripped. And, that’s not enough to take someone off a blood thinner.
[00:54] And, I know that very much from a patient of mine who I’ve been taking care of for almost 25 years. I tried my darndest to tell the doctor not to take — she was a high stroke risk — and he stopped it because he thought she was “falling.”
[01:09] She had a major stroke. She’s been in a wheelchair for over a decade. I see her twice a year. Every time I see her, I’m reminded what a mistake that was to stop her warfarin.
[01:19] So, if you truly are at risk, and if you’re truly falling, and you’ve documented that you’ve fallen and you’ve hit your head, okay, let’s try something else. Maybe they need some left atrial appendage occlusive device or something.
[01:31] But, just because someone is “unsteady” is not a reason to stop blood thinners.
When Do You Consider a Stroke Prevention Device?
[00:09] A lot of patients read about these new devices we have; they can go plug up the left atrial appendage and minimize the stroke risks. And, you know, they’re on websites and afib sites, or they know someone who had it. And, I’m glad they’re up on the data, and up on the concept that they exist. But, what they don’t know is they have very limited clinical use right now.
[00:33] First of all, they don’t work in everybody; I mean, just like blood thinners. I mean, not every stroke comes from the left atrial appendage. So, they need to know there’s still some residual risk.
[00:46] And, they’re not for everybody. So, if you can take a blood thinner, and you’ve been doing well on a blood thinner, usually you’re not a candidate for it.
[00:52] I reserve them — I don’t put them in, but I’ve sent them to be put in by one of my partners — I’ve reserved it for people who absolutely worry me as far as the stroke risk, but are either contraindicated, or relatively contraindicated, to a blood thinner.
[01:08] I have a patient, not long ago, who had three gastrointestinal bleeds on one of the DOACs. That’s enough. I mean, it required six units of blood. That person cannot be on a blood thinner long-term, and I’ve referred that person for consideration of one of these devices.
[01:26] But, at the moment, they’re not for everybody. They have to be used selectively, but they are valuable, and they should be part of your armamentarium.
How Do You Choose Between Warfarin and DOACs?
[00:09] During the discussion of anticoagulation, it’s important to talk about two different roads. One is the classic warfarin that requires, usually, monthly INR checks. And, the other are these new drugs, so-called Direct Oral Anticoagulants, or DOACs.
[00:27] They should both be brought up in the discussion, with risks and benefits, and advantages and disadvantages, mostly, of discussion.
[00:36] So, I usually tell a patient, “If you want to take warfarin, we’ll be able to track your actual blood thinning. We’ll know, from a lot of experience, if you’re in the range or not. And, we can adjust accordingly. You do have to have monthly blood checks. There are foods and other things that interact, but it’s fine. I mean, there’s nothing wrong with being on warfarin. If you take one of these DOACs, you need to know they’re dose-related. And, no, there’s not a blood test I can do to say how protected you are. You just have to accept the fact that you’re protected because all the studies showed, at this dose, you had at least as good of an effect against warfarin, and sometimes better.”
[01:15] So, what’s the downside of them? It’s usually cost, quite frankly; and, if you get into a Medicare age group, they can be cost prohibitive. So, you just have to discuss both.
[01:27] Some patients actually like the idea of knowing that they’re protected. They know an INR number. I’m okay with that. That’s fine with me. We teach them how to do warfarin. Some people have bad kidney function, and then they have to be on warfarin. Okay? Or, some people have artificial valves, and they have to be on warfarin.
[01:45] But, if you can take both, my own bias is I like to give you one of the newer drugs. Compliance, in my experience, is better. They’re easier to take. They’re more user-friendly. If your wallet doesn’t get diuresed — you know, and you can’t afford them — then I would prefer some of the newer drugs. I don’t see any downside to them regarding that.
[02:05] But, if you’re in a group that can’t afford them, I would suggest warfarin, and not say it’s terrible. I mean, you will get patients come in and go, “That’s rat poison, Prystowsky. I’m not taking it.” Actually, it is rat poison, you know? So be it; I mean, but it works.
[02:21] So, I think the discussion has to be made, benefits and risks of both; cost has to be taken into account; and then, let the patient make a decision.
How Do You Stop or Change Warfarin or DOACs?
[00:09] Two issues occur that require alteration of anticoagulant therapy.
[00:14] The most common is the patient is going to undergo a procedure, often a colonoscopy, and the gastroenterologist will not do it without stopping the drugs, whether it be warfarin or a DOAC.
[00:29] We have a standard reply to that. We tell them that there is a risk of stroke; it’s very small, but there is a risk, and you have to accept that. They won’t do the procedure, in my experience, unless we stop it; or, they’re undergoing surgery.
[00:40] So, those situations are black and white. Either you stop it and get the procedure, or you just keep going on and the procedure’s not going to be done. And, that’s a decision you just have to make.
[00:52] My guidance to both the patient and the doctor is, there is a small risk — it’s very small, but there’s a small risk — and to please minimize time off the anticoagulant.
[01:01] A different issue is when you have to switch from one anticoagulant to another, and there are guidances on this.
[01:08] If it’s a DOAC to a DOAC, let’s say, apixaban to rivaroxaban, okay? One is twice a day, one is once a day, but the guidance is, when your next dose is due, you just switch over. And, usually, this is a smooth transition. I’ve done that many times with patients. You do have to make sure there’s no drug-drug interactions with the new drug. Sometimes, there are. Not all drugs work through the same elimination pathways in the body. So, you have to check that.
[01:35] The biggest one, that I actually don’t keep in my head, I look up, is the warfarin to a DOAC, or a DOAC to warfarin. Sometimes, for whatever reason, patient decides I’m off of this, I want to be on that. Those are different depending on the drug. And, what you have to do, and it’s in a lot of programs that doctors can get on their phones, they’ll give you instructions. They’ll say, “Stop this, check this, start this when this is this,” and I just follow the rules.
[02:02] I mean, they’re not all the same, so it’s not something I personally commit to memory. I just look it up when a person has to switch, and I give them the rules.
What Do You Do When Patients Forget Medications?
[00:09] One of the issues that comes up occasionally in the office is a patient who is more elderly and is starting to forget things, and I always try to, and they’re on warfarin, let’s say, but they could be on a DOAC, too. And, I’ll have a serious chat with the family members because, not infrequently, they’re living at home still; I mean, they’re living in their own home.
[00:31] If they’re in a controlled environment, like a nursing home or assisted living, where there’s somebody who can check their medicines, it’s a little different. But, not infrequently, they’re still on their own. And, one of the concerns I have, and the family members have, is are they taking their medicines? Because this an area you can’t mess with. If you’re in persistent afib, and you’re more elderly, and you have a bunch of risk factors for stroke, either you take too much, and you have a major bleed, or not enough, and you have a stroke.
[00:57] These are tough questions to ask. And, I’ve actually made some recommendations at times to family that either they have an aide come in daily, and make sure they get their meds, or they consider moving them to a different facility because this is a dangerous situation and you must take these medicines. They’re protective of your brain, and you can’t mess this one up.
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