Sign-in to Ask A Doctor - 24x7
OR
Sign in with Google
Suggest Remedy For Atrial Fibrillation And Flutters After Suffering From Cryptogenic Stroke
Question: I am a 42 year old female, previously healthy and 19 months postpartum. I had a cryptogenic stroke on feb 22, a pfo was found on tee, and I had a pfo closure via catheter with gore helex device on May 28. Two weeks later (after returning to work), I began having lots of afib and flutter. Your thoughts? Could this be temporary and stress related? Or is it reasonable to revise the theory of the stroke and keep me on coumadin for life? Dr. C. (Phd, not MD)
Brief Answer:
should consider alternative diagnosis and start temporary anticoagulant .
Detailed Answer:
hello Dr C , i will be little more advanced in discussion considering your educational background
1) the incidence of pfo in normal population is 25 % , that is every one person among four has a pfo , but rarely they experience stroke , rather if we go by statistics it is 28 per 100000 ppl with pfo may have stroke . so though a well known cause of paradoxical embolisation pfo is still a rare cause . however because it was post pregnancy (pro coagulant state ie. more chances of clot formation) and no other cause was identified , closing the pfo may be justified.
2) now new onset atrial fibrillation may occur post device closure through again very rare and even less with helex device . less than 2 % and in majority its a benign event and a single event
so now the main question was the previous stroke caused by paroxysmal AF which were sub clinical or was this event of AF the 1st one .
Dr .C , whatever be the reason of AF , if we follow the XXXXXXX or european guidelines you should be started on coumarin (alternative s Are available) till the cause is determined .
if the isolated episode is old , and nothing is done you may wait and watch even nxt episode start anti coagulation as the chances is highest during the episode nad three weeks post .
the decision here has to be individualised based on the merits oand demerits of starting the coumarin .whats your cha2ds2vas / hasbled score.
Hoping i may have helped though we are on a sticky platform and a balanced disscusion with your doctor and you may help
should consider alternative diagnosis and start temporary anticoagulant .
Detailed Answer:
hello Dr C , i will be little more advanced in discussion considering your educational background
1) the incidence of pfo in normal population is 25 % , that is every one person among four has a pfo , but rarely they experience stroke , rather if we go by statistics it is 28 per 100000 ppl with pfo may have stroke . so though a well known cause of paradoxical embolisation pfo is still a rare cause . however because it was post pregnancy (pro coagulant state ie. more chances of clot formation) and no other cause was identified , closing the pfo may be justified.
2) now new onset atrial fibrillation may occur post device closure through again very rare and even less with helex device . less than 2 % and in majority its a benign event and a single event
so now the main question was the previous stroke caused by paroxysmal AF which were sub clinical or was this event of AF the 1st one .
Dr .C , whatever be the reason of AF , if we follow the XXXXXXX or european guidelines you should be started on coumarin (alternative s Are available) till the cause is determined .
if the isolated episode is old , and nothing is done you may wait and watch even nxt episode start anti coagulation as the chances is highest during the episode nad three weeks post .
the decision here has to be individualised based on the merits oand demerits of starting the coumarin .whats your cha2ds2vas / hasbled score.
Hoping i may have helped though we are on a sticky platform and a balanced disscusion with your doctor and you may help
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
Thank you for your thoughtful reply. I am of course in ongoing consultation with my cardiologist, my cardiac interventionist's nurse practitioner, and my internist.
After the stroke, I was placed on 325 mg aspirin and 75 mg plavix. After the pfo closure, the aspirin dose was dropped to 81 mg, and the plan was to stop plavix 6 weeks post op and continue 81 mg aspirin for life.
I had some mild transient palpitations for 24 hours after the surgery, and then the went away and then I was fine and symptom-free from days 2 to 14 after closure. I then began to experience very strong palpitations, very frequently throughout the day. They seemed to get worse, and felt like they lasted anywhere from 15 minutes to 3 hours. We scheduled a holter monitor and I have upload the summary analysis for your review.
When my cardiologist saw the holter, he immediately put me on coumadin and a beta blocker. (Alternatives to coumadin were offered, but my internist was concerned about reversal. At this time the required blood tests are not too inconvenient because luckily my internist's office is across the hall from mine. So she will draw blood and report results to the cardiologist.)
My main concerns at this point are:
1) Is the afib likely temporary, and what could be causing it?
2) How likely is it that I will have to be on strong blood thinners for life? (The whole purpose of having the pfo closed was to avoid having to take blood thinners).
What do you mean by "if the isolated episode is old"?
My chads score is 3.
After the stroke, I was placed on 325 mg aspirin and 75 mg plavix. After the pfo closure, the aspirin dose was dropped to 81 mg, and the plan was to stop plavix 6 weeks post op and continue 81 mg aspirin for life.
I had some mild transient palpitations for 24 hours after the surgery, and then the went away and then I was fine and symptom-free from days 2 to 14 after closure. I then began to experience very strong palpitations, very frequently throughout the day. They seemed to get worse, and felt like they lasted anywhere from 15 minutes to 3 hours. We scheduled a holter monitor and I have upload the summary analysis for your review.
When my cardiologist saw the holter, he immediately put me on coumadin and a beta blocker. (Alternatives to coumadin were offered, but my internist was concerned about reversal. At this time the required blood tests are not too inconvenient because luckily my internist's office is across the hall from mine. So she will draw blood and report results to the cardiologist.)
My main concerns at this point are:
1) Is the afib likely temporary, and what could be causing it?
2) How likely is it that I will have to be on strong blood thinners for life? (The whole purpose of having the pfo closed was to avoid having to take blood thinners).
What do you mean by "if the isolated episode is old"?
My chads score is 3.
Brief Answer:
beta blockers and anticoagulation till no episode af !F occurs
Detailed Answer:
hello , i did go through the reports
as we discuss i will still stress that all will have to be individualised on case to case basis as there are no multi centric trials yet published which can guide us on what to do i this particular condition .
based on the holter , there is no doubt that you needed both anticoagulation / beta blockers .
Now coming to your question >
1) AF may be temporary . the procedure of device closure itself is a precipitaing cause , where new onset AF in seen in 1.5-2 % patients , in less than half it may persist ..
the above sentence is based on review of many studies
2) how long anticoagulation > to be XXXXXXX if AF nvr occurs minimum 4 to 6 months as per your doctor , if recurrence even subclinical than life long .
so how will we know it was isolated , you will be the best to feel palpitations and a loop recorder or ekg at the time will prove the rhythm during such episode . if no episode you can slowly reduce the dose of beta blocker before omitting and see if there is any episode .
3) i would suggest that you dont take dual antiplatlet aspirin with clopidogrel and coumarin simultaneouly as the risk of bleeing is very high. Even XXXXXXX guidelines say that its single antiplatelet preferably clopidogrel with coumarin to be taken .
by isolated episode i meant a single episode before 6 weeks and still no coumarin started , then we can still wait as XXXXXXX chance of embolisation is in initial part due to stunning of LA post cardioversion , however holter loops show otherwise and so his point doesnt stay valid.
chads score in you wouldnt hold much because we dont know wheather the cause od stoke was Atrial fibrillation or PFO
regards . hopfully i could help
beta blockers and anticoagulation till no episode af !F occurs
Detailed Answer:
hello , i did go through the reports
as we discuss i will still stress that all will have to be individualised on case to case basis as there are no multi centric trials yet published which can guide us on what to do i this particular condition .
based on the holter , there is no doubt that you needed both anticoagulation / beta blockers .
Now coming to your question >
1) AF may be temporary . the procedure of device closure itself is a precipitaing cause , where new onset AF in seen in 1.5-2 % patients , in less than half it may persist ..
the above sentence is based on review of many studies
2) how long anticoagulation > to be XXXXXXX if AF nvr occurs minimum 4 to 6 months as per your doctor , if recurrence even subclinical than life long .
so how will we know it was isolated , you will be the best to feel palpitations and a loop recorder or ekg at the time will prove the rhythm during such episode . if no episode you can slowly reduce the dose of beta blocker before omitting and see if there is any episode .
3) i would suggest that you dont take dual antiplatlet aspirin with clopidogrel and coumarin simultaneouly as the risk of bleeing is very high. Even XXXXXXX guidelines say that its single antiplatelet preferably clopidogrel with coumarin to be taken .
by isolated episode i meant a single episode before 6 weeks and still no coumarin started , then we can still wait as XXXXXXX chance of embolisation is in initial part due to stunning of LA post cardioversion , however holter loops show otherwise and so his point doesnt stay valid.
chads score in you wouldnt hold much because we dont know wheather the cause od stoke was Atrial fibrillation or PFO
regards . hopfully i could help
Note: For further queries related to coronary artery disease and prevention, click here.
Above answer was peer-reviewed by :
Dr. Vaishalee Punj
Answered by
Get personalised answers from verified doctor in minutes across 80+ specialties
