Atrial fibrillation patient hesitant to take blood thinners

Dear Dr. Roach: I am an active 76-year-old man.

I became aware of an increase in my resting heart rate in April 2021, going from a resting rate of 48 to 74 beats per minute in a six-day period. It is persistent.

This led me to a cardiologist who diagnosed me with atrial fibrillation three weeks ago. I bruise and bleed easily, and do not want to take more blood thinners. I had a CHA2DS2-VASC score of 2.

Both my cardiologist and electrophysiologist confirmed there is a 2.2% to 2.5% chance of stroke from nonvalvular-related Afib with a 1% chance of stroke even if taking blood thinners. Both immediately recommended Xarelto, Eliquis or at a minimum an aspirin a day.

My math tells me that taking blood thinners provides a 1.2% to 1.5% benefit in preventing a stroke. Do you concur with that assessment? Isn’t that a low-risk number for the negative side effects blood thinners produce in me?

Currently I am taking metoprolol. My resting heart has come from 74 bpm down to 67.

I do not want to take any blood thinners. I am leaning toward having a WATCHMAN device implanted and trying Tikosyn to see if it can return me to sinus rhythm.

— J.T.

Atrial fibrillation is a common problem in which the natural rhythm of the heart is disturbed.

The heart rate often increases, and people are at higher risk for a stroke.

Treatment is designed to bring the heart rate to near-normal and to reduce stroke risk.

The metoprolol has accomplished the first part. Dofetilide (Tikosyn) is an anti-arrhythmic.

The CHA2DS2-VASC score is a way of classifying risk of stroke. The numbers you quote come directly from the study, but it’s important to recognize that these are the risks of a stroke every year.

In the next 10 years, that’s something like a 22% to 25% risk of stroke with no medication versus a 10% risk on anticoagulant medication. If you have ever seen a person with a severe stroke, I think you would not be so quick to dismiss the risk.

There is a risk of taking the medication: worsening of your easy bleeding and bruising. For people who do not want to take an anticoagulant, the WATCHMAN device is a reasonable alternative.

The WATCHMAN device (or the newer-generation WATCHMAN FLX device) is designed to block the part of the heart where most blood clots come from, called the left atrial appendage.

The most recent data suggests that the benefit from the WATCHMAN device in preventing stroke is similar to anticoagulation.

However, a study just released in October suggested that lower-dose anticoagulation even after WATCHMAN placement reduced the risk of adverse outcomes, including stroke, bleeding, and clotting in the device.