Should I take these new heart tablets?
I’VE had atrial fibrillation for the past ten years. My doctor says I need to go on to rivaroxaban tablets. I have my doubts because I believe it can cause bleeds on the brain, but if I remain on the aspirin I’ve been taking, I could have a stroke, so I am between the devil and the deep blue sea. I am 72 years young. Can you advise me?
Name and address withheld.
AS yOU say, this is a predicament for you, and there i s what seems like a difficult decision to make. Atrial fibrillation is one of the most common abnormal heart rhythms, affecting about 10 per cent of people aged 80, and at least 5 per cent of people your age.
Normally the heart contracts to force blood out around the body and then relaxes so that it can fill again. In atrial fibrillation, the atria, the upper chambers of the heart, effectively squirm.
The condition also causes the lower chambers, the right and left ventricles, the main pumping chambers, to beat and pump irregularly. Because the upper chambers are not pushing blood through as effectively as normal, the blood here can pool and clot, and the clots can be washed along clogging up blood vessels elsewhere in the body, causing damage, and potentially a stroke.
This is why we look at inhibiting the clotting mechanism slightly.
To do this, the usual choice is between a daily low-dose aspirin that reduces the stickiness of the blood, and therefore its ability to form clots, and warfarin, which slows the rate at which the blood clots.
Aspirin is easy and convenient but far less efficient than warfarin, but warfarin is difficult to use as it requires regular blood tests to check that it is functioning at the correct level — too high a dose and there’s a risk of excessive bleeding; too low, and there’s still a risk of clots.
So the dose may have to be frequently adjusted as the effectiveness of the drug can vary depending upon what you’ve been eating and other factors. This is why patients on warfarin have blood tests every few weeks, either MeDICS at their GP clinic or hospital.
hoped f or years that something better would come along that offered the ease of aspirin and the benefits of a perfectly controlled warfarin dose. Then three new drugs arrived all at once: rivaroxaban, apixaban and dabigatran.
They are not perfect — potential side-effects include indigestion, and because they are new and have been subject to extensive research and development, they are expensive.
However, no blood tests are needed ( although t here is evidence that blood tests would make one of the drugs, dabigatran — brand name Pradaxa — safer and more effective).
The scare story that has alarmed you is that if you were to suffer a brain haemorrhage — the type of stroke that results from a burst blood vessel — the bleeding would be worse because you’re on a drug to prevent blood clots.
However, most of us would agree that, in weighing up the risks and benefits, you are better off to take the rivaroxaban than not — assuming there are no other major risks for a brain haemorrhage such as poorly controlled high blood pressure. I hope that this explanation helps you to make a confident choice. BOTH my doctor and my optician have diagnosed that I have visual migraine. I lose focus for between 20 and 40 minutes each day, about five or six times daily. I only know it happens if I am reading or playing golf or snooker. Nobody seems to know what causes it, and nobody has given me advice to make it better. Please can you give me some information that might help me lead a better quality of life. I am 84.
F. R. Bannister, Romsey, Hants. MIGRAINe is an affliction which comes in episodes. Normally, the main symptom is a severe headache, but often this will be accompanied by nausea or sensitivity to light or noise.
A migraine usually starts with some warning signs of the pending attack, such as fatigue, mood changes such as depression or elation, irritability or craving sweet food.
These early symptoms merge in to an aura — visual disturbances such as seeing stars, or seeing blind spots. This is then followed by the headache itself, and after that comes a recovery period, which often gives rise to a sense of great relief or exhaustion.
About a quarter of those who s uf fe r f r om migraine wil l experience aura of some kind — this may not i nvolve visual symptoms, but may instead result i n other sensations such as tinnitus (unexplained noises in the ear) or tingling or burning in part of the body.
Other symptoms include loss of vision or hearing or sensation. There is a rare variant called retinal or ocular migraine.
This is characterised by frequent attacks of blindness lasting for several minutes or even up to an hour, followed by a headache.
Far more common is for people to have an aura without the subsequent headache: I have seen this in patients on a few occasions, and it is likely that this is what is happening in your case — at least that is what your doctor and optician have concluded. However, I do find myself questioning your current diagnosis as you are having so many episodes, several each day.
Normally, migraine aura occurs perhaps once or twice a year or several times in a month at most.
The other oddity in your case is that these episodes only seem to occur when you are using your vision for the tasks you mention, such as playing golf.
Usually, the onset of migraine is more random than that, though I accept that it is difficult to generalise as for some people there are specific triggers such as fatigue or alcohol.
In a person of your age I do think it is important to rule out the possibility that the episodes might be transient ischaemic THeSe attacks or TIAs.
are mini strokes caused by a temporary disruption of the blood supply to the brain. Unlike a full stroke, the symptoms are short lived.
If this is the case, you may need treatment with medication such as aspirin. So i f you keep experiencing this many episodes it could be worth asking your GP to refer you to a neurologist.
They may ei t her suggest pr ev e n t i v e tr e a t ment, or investigations such as a scan of the arteries in the neck that supply blood to the brain.
either should result i n an improvement to your current quality of life.
WRITE TO DR SCURR
TO CONTACT Dr Scurr with a health query, write to him at Good Health, Scottish Daily Mail, 20 Waterloo Street, Glasgow G2 6DB or email drmartin@dailymail.co.uk — including contact details. Dr Scurr cannot enter into personal correspondence. His replies cannot apply to individual cases and should be taken in a general context. Always consult your own GP with any health worries.