AFib--advocate for anticoagulants for dh?

[Acadie]

Dh has had AFib before, last episode about 15 years ago. In the ER Thursday night they were initially going to discharge him on metoprolol and anticoagulants, and refer him to cardiology for follow up within 5 days. But then they consulted the algorithm that says he's low risk for stroke, and decided last minute no anticoagulants. Really wish we'd pushed for it then, but we were both exhausted and not thinking straight. 

Cardiology has no openings for 11 days. He's still in AFib. He was on anticoagulants while out of rhythm years ago, and my understanding is if he remains in AFib cardiology would put him on anticoagulants before attempting cardioversion anyway. ER did not attempt cardioversion. 

There's clotting history in his family--his dad had a stroke secondary to AFib and has not completely recovered cognitive function. His mom also has AFib and has had multiple PEs and DVTs. Both our daughters had Covid toes, which docs said is micro clots settled in lower extremities. 

Primary care declined to add anticoagulants when he requested on MyChart, saying they agree with ER assessment. 

We need to write back and emphasize family history of clotting, stroke, PE, DVT, right? And that ER doc emphasized to us he should see cardiology within 5 days, but 11 day delay may change the assessment? He's 53, not a fall risk, suspending intense workouts until he sees cardiologist.

Edited March 25, 2023 by Acadie

[sassenach]

He should absolutely be on anticoagulants. I'm so surprised with his hx that there's any question. He will likely be fine waiting the 11 days but I would push the cardiologist if there's any question. 

[Acadie]

1 minute ago, sassenach said:

He should absolutely be on anticoagulants. I'm so surprised with his hx that there's any question. He will likely be fine waiting the 11 days but I would push the cardiologist if there's any question. 

Thanks so much. Second guessing myself given two docs not prescribing and appreciate your clarity. 

[Katy]

IDK how the guidelines have changed, but I think they have as something similar happened to a family member recently. In the meantime, baby aspirin and turmeric are OTC. 

[kbutton]

I hope you get what he needs without hassle. The clotting history is concerning.

Some people don’t have a lot of symptoms with clots, so don’t feel odd about taking any symptoms seriously!

If there is a known cause for the familial clotting, that might help you make a stronger case.

It’s also blood clot awareness month, so you might find some really good resources on social media to help advocate for him.

[Amethyst]

My dh was very low risk also when he went into aFib. They still had him on anticoagulant until his cardioversion. 

[Shelydon]

I might return to a different ER and request a cardioversion

[Acadie]

1 hour ago, Amethyst said:

My dh was very low risk also when he went into aFib. They still had him on anticoagulant until his cardioversion. 

This is helpful to hear, thank you.

[Acadie]

1 hour ago, Shelydon said:

I might return to a different ER and request a cardioversion

He was the perfect candidate when he went to the ER because it had been just a couple hours. I'm so mad they didn't try. They said they were going to, but then decided not to because they couldn't be sure when his heart went out of rhythm. He is sure--as an athlete with a history of AFib he's very tuned in, and literally felt it change while he was eating dinner.

He's about 46 hours out and we're hesitant to risk Covid etc in the ER again. Last time he was there for 5 hours. Wondering what are the chances they'd try, since the first doc didn't and he's nearing the end of the window. 

[Amethyst]

10 minutes ago, Acadie said:

This is helpful to hear, thank you.

But my dh saw a cardiologist in the ER. We would have liked for him to be cardioverted immediately, but in the US they tend not to do this. His was new onset AFib, your dh's is not. The CHADS VASC score is probably what they used to determine anticoag or not, and from what you're saying he has a low score. Like someone previously said, they will prob want to anticoagulate him prior to cardioversion. And of course, will they might not decide to go the caradioversion route. Lots to discuss with the cardiologist.

(aspirin is not an anticoagulant, so I'm not sure that would be helpful)

[Amethyst]

4 minutes ago, Acadie said:

He was the perfect candidate when he went to the ER because it had been just a couple hours. I'm so mad they didn't try. They said they were going to, but then decided not to because they couldn't be sure when his heart went out of rhythm. He is sure--as an athlete with a history of AFib he's very tuned in, and literally felt it change while he was eating dinner.

 

I feel you. My dh knew exactly when he went into AFib too. In Canada, they probably would have done it immediately. But that's not protocol here.

[Acadie]

Thanks so much, everyone!

With this advice I think pushing for anticoagulants is the way to go. That would set him up for his cardiologist appt in 11 days and addresses clotting risk until then. As much as I wish they tried to cardiovert him earlier it seems that may be a bridge too far at this point. 

[EKS]

Does he have a primary care physician?  You might be able to get meds through them and possibly speed up the cardiology appointment.

[Acadie]

16 minutes ago, EKS said:

Does he have a primary care physician?  You might be able to get meds through them and possibly speed up the cardiology appointment.

Yes, thank you, that's the doc he's going to message again to ask about meds.

He sent one message already, and her office just gave him the general cardiology scheduling number and said she wouldn't prescribe anticoagulants because she agreed with ER assessment. Hopefully she'll change her mind with more info on family history.

His former cardiologist retired, and since he hadn't had issues in 15 years he doesn't currently have a specialist. That meant a longer wait for a new patient appointment. If anyone is in the same boat, definitely get established as a new cardiology patient before you have urgent need! Cardiology is absolutely swamped with Covid, and will be for the foreseeable future. 

[wathe]

It's a matter of balancing thromboembolic risk with bleeding risk. Anticoagulation is not benign.  If MD judges that bleeding risk on thinners > ischemic stroke risk without thinners, then MD will advise against anticoagulation.  

ED MD probably used  CHA2DS2-VASc tool to evaluate risk.  If the score is low, then it's likely that bleeding risk outweighs clotting risk, and therefore unlikely that  thinners would be started from the ED.    Starting a patient who doesn't meet criteria on thinners from the ED isn't really defensible, and  ED MD's have all seen catastrophic bleeding events in patients on thinners.  Intracranial hemorrhage is no picnic, nor is GI bleed;  

I wonder if you might benefit from further discussion with your PCP, in order to more fully understand the risk/benefit trade-off in your DH's particular case.

[Mom_to3]

On 3/25/2023 at 4:40 PM, Amethyst said:

I feel you. My dh knew exactly when he went into AFib too. In Canada, they probably would have done it immediately. But that's not protocol here.

Hmm, any idea why? I wonder what the reason for the difference in protocol is. It can't be that Canadians are more reliable in reporting onset than Americans?! May be a good reason to get a device like an Apple Watch or do a daily Kardia to be able to prove timing of onset?

[Amethyst]

37 minutes ago, Mom_to3 said:

Hmm, any idea why? I wonder what the reason for the difference in protocol is. It can't be that Canadians are more reliable in reporting onset than Americans?! May be a good reason to get a device like an Apple Watch or do a daily Kardia to be able to prove timing of onset?

I don’t know why. And I could be wrong. I just remember dh and the cardiologist discussing this. I also remember them discussing the pill-in-the-pocket approach. 

[Guest]

Nm

Edited March 26, 2023 by WTM

[wathe]

5 hours ago, Mom_to3 said:

Hmm, any idea why? I wonder what the reason for the difference in protocol is. It can't be that Canadians are more reliable in reporting onset than Americans?! May be a good reason to get a device like an Apple Watch or do a daily Kardia to be able to prove timing of onset?

Medical culture shaped by liability is the most likely reason, I think.  Cardioversion in the ED has risk: increased sedation risk (pt not NPO, limited pre-proceedure workup) and stroke risk (duration of a fib based on history alone, pt not anticoagulated, limited pre-preoceedure workup) and the risks added by the rushed, chaotic environment --staff are frequently distracted and interrupted. Definitely riskier than elective cardioversion.  Not cardioverting in the ED is much less medico-legally risky for the doc (for stable patients) and for the hospital too.  Cardioversion is also resource intensive; this is a disincentive in packed, under-resourced EDs.  There may also be direct or indirect financial reasons (cost to hospital, emergency vs elective billing, opportunity cost to MD who could be seeing other patients etc) that are different in the US health-insurance/hospital funding environment vs Canadian environment; this last one is just a guess.

ETA: I don't think the difference has anything to do with what's actually best for the patient, sadly.

Edited March 27, 2023 by wathe