Coumadin and a Pacemaker

[frank42]

My husband was diagnosed with afib while in the hospital with his second ruptured hepatic aneurysm in Dec. 2007.  He also had a severely ulcerated stomach from the insertion of the coils to stop the bleeding.  Both of his legs were also full of clots.  On 1/15/08, he had a pacemaker and an ablation.  Once the stomach was healed, he began a treatment of Coumadin which has been difficult to regulate.  He has to come off the Coumadin for a week before he has a throat dilatation, which occurs every 8-10 weeks as a result of scar tissue from his colonic interposition to treat his esophageal cancer and first ruptured hepatic aneurysm on 3/11/02.  He also experienced afib several times, along with two pulmonary embolisms and a clot during the 3/11/02 hospital stay and was on Coumadin for 6 months.  On 9/19/02, he suffered either a minor stroke or a TIA, which left him paralyzed on the left side for a little over 24 hours.  He was released from the hospital and was on Aggrenox until 2/17/05.  He had to go back to the hospital 11/30-12/02/08 for internal bleeding which was traced to his INR being 3.4.  While in the hospital, they stopped the Coumadin and gave him plasma to raise his INR and did another endoscopy to check on the bleeding.  He is fine now, but he wonders if he really needs the Coumadin since he already has a pacemaker and he has a problem with bleeding.  Obviously, he has a very complicated medical history and we want to simply it as much as possible.  Thank you.  

[Cleveland Clinic]

There are risks and benefits to treatment with every medication. Coumadin will continue to decrease his risk for an embolic stroke and TIA by 30%. Since his risk of having an embolic event is very high, probably in the range of 6%/ year, treatment with this drug would be advocated in most patients. However, in your husband's particular case this has to be weighed against the very high risk of bleeding, which I am estimating as probably the same as the risk of TIA or stroke per year with the Afib. Having had an AVN ablation does nothing to tret the A fib, as the atrium stays in Afib, but by ablating the AVN this stops the impulses from reaching the ventricles. Hence, coumadin is still advocated. However, a new type of ablation called PVI which cures a fib in the majority of patients. He also has another indication for coumadin which is DVT and PEs, and the risk of recurrence of these is very high.
So, as stated above, the risk of prevention of a TIA/ stroke is balanced by a risk of causing bleeding. It is up to the patient to decide which risk they prefer having.