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Done A-fib Ablation. Have Atrial Septal Aneurysm. Have CHADS Score 1. Want To Stop Coumadin And Aspirin
Question: I recently had an afib ablation which was successful. Now after 4 months I am hoping to get off coumadin and on aspirin. I learned however through a pre ablation TEE that I have a previously unknown atrial septal aneurysm with pfo that has never given me any symptoms. I am 63. My cardiologist says my ASA with PFO is small and he is not concerned and that I can go on aspirin or coumadin with a CHADS score of 1. (hx htn) My EP wants me on coumadin for life saying that he uses the CHADSVASC score and my score is 2 (hx htn and female. ) I am concerned that my stroke risk is greatly increased by the COMBINATION of all of the above factors, but I still have a CHADS score of 1 and would like to go off coumadin and on aspirin if it is not foolish to do so. Since my doctors don't agree I have to make up my own mind and would like to hear from a specialist with experience in these areas. I have researched the internet on the subjects, and there is not alot of info on all three issues together. I have been a registered nurse for 40 years and feel I know when I go into afib so I would know if I went back in.
Respected Ma'm
1. Current thinking on Atrial septal aneurysm is not very supportive of initiating coumadin like drugs. In fact for patients with ASA with or without PFO, no therapy is recommended for primary prophylaxis (for prevention of first episode of stroke/ embolic event), in the absence of other risk factors.
Even in patients with ASA/PFO and a cryptogenic stroke, ACC and ACCP both recommend use of aspirin like drugs and not coumadins. Hence ASA/PFO is not under consideration when we discuss anti-coagulation strategy in your case.
2. As per ACC/AHA guidelines, you have one moderate risk factor and one low risk factor for which guidelines, are not direct but, indirectly support use of coumadin like drugs. Moreover, in patients of AF (even after ablation) risk for thrombo-embolism is not guided by absence/ presence of AF but by risk factors for thrmobo-embolism which were previously present. Hence your electrophysiologist is a much better judge of the things as he knows how your atria was, how many scars he created, what are the chances of recurrence etc. One important objective factor will be size of your left atrium.
3. I appreciate your confidence that you will be able to know when AF is there, but it may happen at times when you are unaware, like sleeping.
I hope it provides some insight into the issue for you to take a decision.
Feel free to discuss further.
Sincerely
Sukhvinder
1. Current thinking on Atrial septal aneurysm is not very supportive of initiating coumadin like drugs. In fact for patients with ASA with or without PFO, no therapy is recommended for primary prophylaxis (for prevention of first episode of stroke/ embolic event), in the absence of other risk factors.
Even in patients with ASA/PFO and a cryptogenic stroke, ACC and ACCP both recommend use of aspirin like drugs and not coumadins. Hence ASA/PFO is not under consideration when we discuss anti-coagulation strategy in your case.
2. As per ACC/AHA guidelines, you have one moderate risk factor and one low risk factor for which guidelines, are not direct but, indirectly support use of coumadin like drugs. Moreover, in patients of AF (even after ablation) risk for thrombo-embolism is not guided by absence/ presence of AF but by risk factors for thrmobo-embolism which were previously present. Hence your electrophysiologist is a much better judge of the things as he knows how your atria was, how many scars he created, what are the chances of recurrence etc. One important objective factor will be size of your left atrium.
3. I appreciate your confidence that you will be able to know when AF is there, but it may happen at times when you are unaware, like sleeping.
I hope it provides some insight into the issue for you to take a decision.
Feel free to discuss further.
Sincerely
Sukhvinder
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you for your thoughtful and specific response. It seems that some of medical centers are discontinuing coumadin after ablation using the presence or absence of afib as their main criteria. So far the evidence seems like there have been few problems. Many others of course do not do that. My atria were described as mildly to moderately enlarged on the TEE one day prior to ablation. Is there a likelyhood of remodeling and shrinkage if I stay in sinus rhythm? 3 years ago when my afib started my left atrial diameter on TTE was 4.1. The CT scan 4 months ago, the week before my ablation, showed my lad as 4.9 but the quality of that study was very bad. ( I breathed at the wrong time. ) Is the 4.9 large enough to be concerned ,if it is correct, could it still shrink?
Respected Ma'm
1. I would go by the conventional thinking as yet. The criteria primarily should be based upon the risk factors & lesser value should be given to presence or absence of AF. Even if chance of recurrence is 5% & patient harbors significant risk factors, the risk of thrombus formation will be significant, if at all AF recurs. I hope you got my point.
2. LA size of 4.9 cm is big, but exact estimation will also depend upon your body surface area. Anyone with body surface area of 2.2m2 or less, 4.9 is high. Higher the LA, more will be chances of recurrence. But this is also governed by other factors too. The shrinkage of LA or reverse remodeling of LA after AF ablation is a well known phenomenon and again depends upon many pre-ablation factors. Hence you can expect shrinkage if you remain in Normal sinus rhythm.
Hope this helps.
Feel free to write if there are more queries.
Sincerely
Sukhvinder
1. I would go by the conventional thinking as yet. The criteria primarily should be based upon the risk factors & lesser value should be given to presence or absence of AF. Even if chance of recurrence is 5% & patient harbors significant risk factors, the risk of thrombus formation will be significant, if at all AF recurs. I hope you got my point.
2. LA size of 4.9 cm is big, but exact estimation will also depend upon your body surface area. Anyone with body surface area of 2.2m2 or less, 4.9 is high. Higher the LA, more will be chances of recurrence. But this is also governed by other factors too. The shrinkage of LA or reverse remodeling of LA after AF ablation is a well known phenomenon and again depends upon many pre-ablation factors. Hence you can expect shrinkage if you remain in Normal sinus rhythm.
Hope this helps.
Feel free to write if there are more queries.
Sincerely
Sukhvinder
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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