Deciding Between Medication and Procedures for Afib Stroke Risk

You will see throughout our website and most other resources about atrial fibrillation or Afib that stroke risk is a significant, often primary concern of the condition. This should not be taken lightly because the risk of stroke is five times higher in patients with Afib than those without. Fortunately, we have effective interventions to prevent or reduce the likelihood of a stroke in Afib patients. In this article, we will discuss how we go about stratifying the risk of stroke and what options we have to manage that risk.

First, We Need to Diagnose Afib

The diagnostic process is relatively straightforward for electrophysiologists. However, many patients are delayed in their diagnosis because they don’t see an appropriate specialist. Most patients will get an EKG at their annual physical with their primary care physician. Yet, EKGs rarely catch paroxysmal or occasional Afib unless you are experiencing it at that moment. Suppose you may think you have an arrhythmia, but your primary care physician or cardiologist has not been able to find an irregular heartbeat. In that case, we encourage you to schedule an appointment with an electrophysiologist who has advanced diagnostic tools at their disposal, including Holter monitors, event monitors, and loop recorders. In case of a challenging diagnosis, we can even do an exploratory electrophysiology study performed in the EP lab to induce an arrhythmia mechanically or chemically. As a bonus, we can perform a catheter ablation on the spot if the situation warrants it.

Next Step, Stratifying Risk

We take great care to stratify the risk of stroke in every Afib patient because not only is the risk of stroke increased by five times versus those who do not have Afib, but ischemic strokes caused by atrial fibrillation are much more severe. Stratifying risk is accomplished using a simple series of questions that include a patient’s age, some demographic information, and an evaluation of other conditions they may have. Knowing their ChA2DS2-VASc score, we can understand whether treatment to prevent stroke is necessary.

Choosing Between Drugs and Procedures for Stroke Mitigation

There are two interventions for patients with high stroke risk. First are pills known as antithrombotic or blood thinning medication. These medicines are highly effective and are almost always the front-line treatment for patients with heightened stroke risk, unlike the balance between anti-arrhythmic drugs and cardiac catheter ablation intervention (where the procedure is often a first-line solution), procedural intervention for stroke risk in the form of left atrial appendage closure is only offered when medical therapy is not indicated. Left atrial appendage closure involves occluding the left atrial appendage using an implant. The two implants currently on the market are the Watchman FLX and the Amulet. Both are safe and effective.

When Is Procedural Intervention Necessary?

There are three circumstances in which procedural intervention may be necessary.

First is when the patient has a significant risk of falling. This is because blood thinners or anti-thrombotic medications reduce the binding properties of blood and can lead to an uncontrolled bleeding event. Older patients who are susceptible to falls or who live a lifestyle where falls could happen may wish to avoid these blood thinners and, by having a procedure, lower the risk of a significant bleeding event.

Second are patients with blood clotting disorders. If a bleeding event is more likely because the patient already has a blood clotting disorder or may be at risk of blood loss issues if they cut themselves or fall, a procedural option may be better than pursuing medication.

Lastly, as with any prescription medication, there are side effects, which, for some, can be severe. Significant side effects are relatively rare, but anti-thrombotic meds can cause sufficient discomfort that the patient discontinues therapy. Of course, discontinuing medical treatment increases the risk of stroke. These patients may be good candidates for procedural intervention.

The Bottom Line

Most importantly, patients need to be correctly diagnosed as early onset, Afib, known as paroxysmal, is most receptive to treatment—later stages become more challenging to treat and consequently more dangerous to the patient. Once evaluated for stroke, patients will likely begin with medication therapy, but various risk factors may push them toward procedural left atrial appendage closure. Most importantly, schedule a consultation with a qualified electrophysiologist like Dr. Tordini to understand your options, including medical or procedure therapy.

Dr. Tordini is a part of Florida Medical Clinic Orlando Health