Greetings, Dr. Roach I have a history of asymptomatic atrial fibrillation (AFib) and I am a 70-year-old woman. Since undergoing two catheter ablations in 2018, my sinus rhythm has returned to normal. Because of the bleeding risk, I would like to stop taking Eliquis, even though my CHA2DS2-VASc score is 2. (Recently, when traveling overseas, I tripped and fell, causing significant bleeding from a small injury.) My physician recommended that I look into a WATCHMAN device after informing me about the OPTION clinical trial.
Could you remark on OPTION, the results of which were just released? According to what I’ve read, the left atrial appendage (LAA) is where 90% of blood clots start. How is the percentage determined? Does this not imply that, despite the study’s findings, a WATCHMAN should be less protective than anticoagulation if around 10% of blood clots originate outside the LAA?
Do you believe that I would make a suitable WATCHMAN? — L.M.
ANSWER: This requires a lot more explanation. Most significantly, the common rhythm abnormality AFib raises the risk of stroke. The main objective for asymptomatic individuals is to control their risk of stroke. Although you have already had a catheter ablation to prevent AFib, your cardiologist is right to keep making sure that your risk of stroke is as low as feasible because catheter ablation is insufficient to lower the risk of stroke.
A doctor uses techniques to predict the risk of stroke and severe bleeding without treatment while deciding how to lower the risk of stroke. The most widely used method of calculating stroke risk is the CHA2DS2-VASc score. Being 70 years old alone earns you 2 points, meaning that, in the absence of treatment, you have a 2.2% annual probability of having a stroke.
When thinking about anticoagulation with a medication like Eliquis, the HAS-BLED bleeding risk score is then computed and compared to the stroke risk.
One type of LAA-occlusion device is the WATCHMAN. It stops clots that form in the LAA (a little section of the left atrium) from escaping to the brain and resulting in a stroke. Numerous studies that used cardiac surgery, echocardiograms, and autopsy to determine the clot’s origin have determined the percentage of clots that originate from the LAA.
Since 10% of clots originate from outside the LAA, not all clots can be prevented with a LAA-occlusion device. But no drug can prevent all clots either; research shows that anticoagulation reduces strokes by roughly 70% when compared to a placebo.
Women are more likely than men to experience side effects during the deployment of a LAA-occlusion device (6% versus 4%). The most frequent side effects were fluid around the heart that needed to be drained and bleeding around the time of implantation.
You won’t get a clear answer if you base your choice on the OPTION study because the trial participants had a far higher risk of stroke than you do. Your main advantage will be a decreased danger of bleeding as well as a decreased risk of stroke. It’s a pretty sensible choice.
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Although he regrets not being able to respond to each letter individually, Dr. Roach will try to include them in the column. Questions can be sent by mail to 628 Virginia Dr., Orlando, FL 32803 or by email to [email protected].
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