There are so many problems with this meta-analysis/study.

First, let's put it in perspective. 2.2% risk versus 1.5% annually. Okay, any difference matters with stroke, but it is only a ,7% risk per year.

Second, given the small difference, it should be noted that many (maybe the majority of) people don't fit one category:

"Prof Gregory Lip (University of Birmingham, UK) agreed on this point. In an email, he wrote, "PAF is heterogeneousa patient with one paroxysm of 1 hour once per year and a patient with paroxysms of AF everyday for 364 days per year will both be categorized as 'paroxysmal AF.' Burden of AF is also heterogeneousarrhythmia burden on 5 minutes today may be 5 hours next month or 5 days in 2 months. . . . Should we 'gamble' and take a risk with an untreated PAF patient with stroke risk factors who may ultimately get a fatal and disabling stroke?"

Third, there is a difference between those that are ALWAYS in afib, and those that are persistent, but switching back and forth. Chronic/longstanding persistent/"always" afib actually has lower stroke risk than afib that switches back and forth from afib to NSR, as that period following restoration to NSR is the time that we are most vulnerable to throwing a clot. If you are never in NSR, you don't have that vulnerable time repeating over and over.

Fourth, what separates paroxysmal versus NON paroxysmal is the 7 day afib burden threshold. It doesn't take a genius to figure out that those that have afib for periods of say 7 hours have less risk than those with over 7 days. The amount of switching matters too. So with all that, .7% is pretty small.

As far as "all cause" mortality in afib patients is concerned, there are more in the persistent group that are sicker... not all, but enough to make a 1.1% difference. So, again, the "absolute" risk isn't high enough to change anticoagulation strategy or life insurance strategy.

So if you ignore the relative risk, and only look at absolute risk, and then bring in all these other factors, this meta analysis doesn't really change anything. What does matter is eating right, exercising, watching your weight, and faithfully taking the best anticoagulant for you.


:-)

petey

Hmmm. Can't open it. It wants your password.

Todd, thanks. How much afib is too much? Enough to not deescalate anticoags for NPAF patients. The affirm trial showed "where stopping anticoagulation with apparent sinus rhythm was associated with strokes." Missing from that trial however were those who were never on an anticoagulant. I was PAF for 14 days and not within range for cardiovert so the EGD was required. If you cant be converted after 48 hours due to stroke risk, I was a few hours past that range Id say. So, NPAF and PAF seem to have about the same risk, or lack there of?
What I would like to see from trials are bleed and other risks, which can have a higher mortality rate.

I agree Hawkman. I'm avoiding anti-coagulants as long as I can. I think the bleeding risks need to be studied vs. the stroke risks. Right now, two EPs said I can do without them for now.

Island, right, I was put on for the 14 days and 3 months after, and never again 6 years ago. I see many on here that have little issue with thinners and swear by them. I would like answers on this subject, but there doesnt seem to be a whole lot of info out there, specifically our questions. There has to be a better way, alternatively speaking. thinners dont thin the blood , but prevent clots. I get that we are in that higher risk. Im wondering what is the percentage of non adherence vs adherence. It doesnt appear that the NPAF group fairs much worse than the PAF group.

I think we individually must be aware and judge what we need. Personally, I've had a DVT, Pulmonary Embolisms, a stroke, AFIB, and bad varicose veins. As far as I'm concerned, I'm on anti coagulants for life, and glad to have them.

Paul's point is well taken. A few comments...risk is not a disease.65% of those with afib that never take an anticoagulant will never have a stroke in their lifetime. But 35% will. If you take an anticoagulant, you can lower that risk to a rate similar to those without afib. An interesting note is that the CHA2DS2Vasc risk factors raise stroke risk for non afibbers, just not as much. So if you get your weight down, eat heart healthy (whatever that is this week), and get a moderate amount of exercise, you can lower your risk. It would seem that taking natural anticoagulants (I don't want to name of endorse them), you could lower stroke risk a little, or maybe more. So maybe (I'm speculating) a person with a low CHA2DS2Vasc score of 2, 1, or 0, can have a lifetime risk of say (I'm making this number up fyi) 20%. So with a little luck, you never take an anticoagulant, don't have a stroke, and don't have an adverse reaction risk that anticoagulants carry with them... but realize that the risks of adverse reactions that are serious, are very small for the NOACs. For me, I would rather test fate and take risk with a $1 investment in a lottery ticket, then test my luck with having a stroke. So I take the anticoagulant, realizing that every drug has effects on the entire body that aren't always good. So then there is the approach of getting an ablation to lower stroke risk. I believe it should lower risk, but not eliminate it. It has its own risks and, if extensive burns are done and contractibility is compromised, you can be in NSR and still have a stroke, due to blood pooling. LAA isolation techniques lower stroke risk, but raise risk of negative outcomes. So there is no perfect answer. Every decision has a positive and negative side to it. We all have to make informed decisions. petey

Good post, Petey.. But I would like to know the risks of a brain or abdominal bleed with anticoagulants. That's the $1,000,000 question. It seems we have to choose whether we want to risk bleeding to death or having a stroke. Neither is very appealing.

Here's an interesting study...

http://stroke.ahajournals.org/content/43/6/1511.full.pdf

Ok.. Found a good chart with the risks and benefits..

http://www.sparctool.com

Bottom line is a bleed is better than a stroke. Death is bad as is an uncontrolled brain bleed or a brain bleed in general. Those things are rare with NOACS when properly prescribed and used (compliance).

I believe they are also rare with a vitamin K antagonist... when properly prescribed and used (compliance).

I take warfarin with 200 mgs of K2, fish oil, Q10 and eat whatever I want. I have an awesome Doc.

I would not recommend anyone doing this on their own.

I am blessed to have so far, the last 3 years one event of afib a year.

In the beginning it was scary and hard, I had lots of afib. In the first year I had clots because I refused to take an bloodthinner. Then I worked out my triggers and have been doing great. I use a BB for a PIP. I sometimes have palpations. I think it has been 6 years since I was diagnosed.

I like this site and wish everyone luck and good Doc's.

I have been on warfarin 6 1/2 years, Theyput me on right away and started in the hospital with shots in the tummy as fastest way. I do not eat greens, Greens to me is spinach, Kale and chard and tops. I was told do not eat greens. Yes I eat lettuce. I eat peas and green beans daily And my vitamin pill .has K. I count my vitamin pill and so to get 90 mcgs a day. Which the blood clinic set. Now I just go to lab to cut costs. Yes, I get monitored.

Yes , I diet and watch what I eat. Wt is where doctor wants it. . walk for exercise. Walking and squeeze balls is all I am allowed. My new doctor could change that, Wait and see. My heart is under control with pills. All un all so pretty good.

My choice is anticoagulants. I'm with Paul. I've had pulmonary embolisms (idiopathic). I figured that with Afib (once the first year, once the second year and so far 4 times this year), I'd be pushing my luck not to use something. I don't notice the NOAC having any adverse effect. Right now I'm happy with my choice.

Petey, enjoyed your thoughts on the article. Thanks.

Todd