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1069105 tn?1256700412

AF & Warfarin bleeding problem

Medical History:
My Mom, age 71,lives in Singapore, has history of hypertension. She was hospitalized in 5/'09 for drug (Hypertension medication: methyldopa) induced Cholestasis prescribed by a new Dr. While hospitalized, she was diagnosed of Atrial Fibrillation (“2DE result: normal LV size & systolic function.  No RWMA. LVEF 59%, Normal PASP 26mmHg.  Trivial aortic & tricuspid regurigation.”)  Aspirin (100 mg) was prescribed. ECG attached. Her hospital's "Chest AP/sitting" result: “The heart size can not be accurately assessed ... but appeared to be enlarged.  There is mild prominence of the hilar vessels, suggestive of mild congestion.”
She was recruited into a Warfarin vs Apixaban double blind clinical trial & started the treatment on Aug-4, 2009.  We later found out that she is on Warfarin w/ dosage unknown to us.
14 days after the Wafarin treatment, she fell (cause of falling unknown, according to her friend who was walking right next to her that my Mom stopped walking forward & dropped on the floor) & hit back of her head.  She was conscious & mobile initially. Repeated brain CT scan in the hospital the same day “due to drop in GCN”. The second CT scan shown a much larger bleed out due to blood thinning effect of Warfarin.  She became semi-conscious & loss senses & control on her left side. CT Brain results: “1. Acute subarachnoid & subdural haemorrhages
2: Pneumocephalus, occipital bone fractures, left haemotympanum & blood products in the sphenoid sinus.
3. Haemorrhagic contusion in left occipital lobe & old lacunar infarct right lentiform nucleus.”
-Her INR is 3.5 (due to Warfarin)

Luckily, after extensive rehab, she was able to regain 90+% of her physical & mental abilities.  She was discharged on 9/11.  The Blood test on Sept 14 during her visit with her Cardiologist:
- Haematology: all within range.  “Platelet clumping noted”
- Biochemistry: non fasting, all within range or non clinical significant

On her follow up visit with the Neurologist, her legs were checked & the Neurologist indicated that she doe not have tendency to embolize.  And the brain CT scan (done in Sept after discharged from hospital) shows blood clot in her brain is almost gone & she is unlikely to have Alzheimer.

Her BP has been in the 110-120/80 ranges.  She has 3 BP medications & one for stomach (1. Amlodipine Besilate 10 mg, 2. Lisinopril 20 mg,3. Atenolol 50 mg, and Omeprazole 20 mg for stomach)

On 9/28, the Cardiologist resumes her with Warfarin (1 mg/day to start with) despite our request to leave the trial & switch to Aspirin.

When we request an echocardiogram, here is the Dr.’s response: “ WE NEED TO DO A TRANSESOPHAGEAL ECHOCARDIOGRAM (A MILDLY INVASIVE PROCEDURE) TO DETECT CLOTS RELIABLY, WHICH IS NOT FEASIBLE. HOWEVER, EVEN IF NO CLOT WAS SEEN, THE RISK FOR CLOT FORMATION IS STILL PRESENT. DOING AN ECHOCARDIOGRAM WILL NOT CHANGE MANAGEMENT.”

With these, here are my questions:
1. Given the patient's near-death bleed out, how safe is it to continue with her blood-thinning therapy?
We, as her family, favor to use aspirin therapy for her AF to mitigate her risk of thromboembolism, as opposed to continuing with Warfarin. But given her near death brain-bleed while using Warfarin, is it wise to use ANY blood thinners now, even low dose aspirin?

2. Should the patient have an echocardiogram to determine the nature and extent of the clotting she is/may be forming due to her AF? What type of echocardiogram? Transthoracic or transesophageal ? What test, if any, can 'see' into the upper chambers of our mother's heart to help us determine to what extent she is building up clots, and therefore help us in forming and evaluating her true risk profile for an embolic event due to her AF?


11 Responses
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88793 tn?1290227177
Hi Carol, I born and grow up in West Malaysia.  Singapore is a very advance medical country as I know of.  All medical expenses there, are very expensive.  When I was a teenager, my heart specialist left and open a new clinic.  I was left in the General Hospital.  Later on a heart specialist (Physician) was employed.  He's from Singapore.  Although a Physician is not specialized in heart but it looked after the whole body.  Not like in Australia, heart specialists also have few categories.  They're all looking after different heart abnormalities.  My heart rhythm doctor only looks at the rhythm and pacemaker.  He won't care the vessels, stroke, anemia etc....   He didn't communicate with other doctors.  When I was diagnosed with TIA in the hospital.  No one notified him and he didn't know I was given Plavix to thin the blood.  He told me I don't need blood thinner treatment so I stopped.  When stroke, you see Neurologist not heart specialist in Melbourne.

I'm glad your mom is doing ok.  Are you living with your mum?  My mum is in KL living with my brother.  She was on a bowl of tablets every morning.  It was for heart, blood pressure, diabetes, etc....  Her doctor (General Hospital) never tell her what kind of heart disease that she has.  She also see one doctor to cover all her illnesses.  Take care.
Helpful - 0
1069105 tn?1256700412
Hi PikaPika88,

My mom is doing ok.  She is never the same after the head injury.  She got another ECG last week & it shows classic AFib (no R & PR readings).  I am still doing research for Q#1 & 2 in my post. Very difficult to find a non-bias Cardiologist in a small island country.

You have lone AF? My understanding is when it (AF) happens, you WILL know & yes, no blood thinner for you (good for you).  Hope your AF can convert back to NSR.

BTW, my Pika is not the same as yours.  "The pika, a cousin of the rabbit, is a small chinchilla-like animal, with short limbs, rounded ears, and short tail."
Helpful - 0
88793 tn?1290227177
Hi Carol, how is your mum?

My cardiologist said that I have AF but mine one is very very short run.  It lasted about 2 minutes so don't need to take blood thinner or medication.   How often?  I don't know and he don't want to tell me.  I got a pacemaker so the pacemaker will record.  He knows how often I have AF.....  It must be not serious.

Your husband must be loved Pokemon too?
Helpful - 0
1069105 tn?1256700412
Thanks you very much.

I'll look into Plavix.

Wow, I looked up BBB & my mom's does looks somewhat like LBBB but some conditions not matching up.  Dr. only mentioned AF, didn't even specify what type of AF.  Managed to find a Dr for a 2rd opinion, hopefully this DR. will be more specific.

BTW, I used the name Pika in a dating site where I met my husband about 5 years ago.  Great name w/ great meaning.
Helpful - 0
88793 tn?1290227177
Hi Carol,  my doctor prescribed Plavix to thin my blood.  He said it won't lower the platelets but still able to thin the blood.   During this Plavix therapy, my platelets which was higher than without taking the Plavix.  I don't know how it works..... it made my period very very heavy and end up I lost a fair bit of blood.  The heamoglobin dropped a few points immediately.  My platelets still stayed in the normal range during my heavy period.

Your mum's ecg showed a bundle branch block.  It looks like mine one.  I don't know is RBBB or LBBB.  May be I'm wrong. Someone in this forum sure can interprete that.  Did the doctor tell you that?  

I hope your mum is getting better.  Take care.
Helpful - 0
1069105 tn?1256700412
Great article.  It makes you wonder.

After spending few days to understand ECG & 2DE reports, I wonder if she really have AF.  I posted it in a different title "AF-misdiagnosed?  ECG & 2DEchocardiogram reports"

Everyone has been so helpful.

Thanks a bunch.

Carol
Helpful - 0
690060 tn?1247841741
NTB
here you go, Carol, it's as if this article/study appeared just for you. I saw it just now and remembered your mother's fall.

http://www.theheart.org/article/1014363.do

"Data from 1.23 million patients confirms warfarin increases mortality in trauma patients"
October 20, 2009

Chicago, IL - Surgeons' suspicion that warfarin (Coumadin, Bristol-Myers Squibb) significantly increases the mortality risk of traumatic injuries in both elderly and younger patients has been confirmed by a large retrospective cohort study...
Helpful - 0
1069105 tn?1256700412
Thank you for the response, really appreciate it.

Her INR seem to be stabilized at 3.5, which according to AHA guideline is high, but according to her Cardiologist it is "correct".

methyldopa was prescribed to her by the doctor in a different clinic, she pick this clinic because it is closer to home.  Her BP used to be at 150 range even with BP medications. I just googled this drug & can see that it is a dangerous drug.  

My mom had 3 serious fell that I am aware of, and with the Atenolol that make her "fatigue, weakness" & "unsteadiness when walking", there might be a good chance that she might fell again.  Hence the concern about Coumadin.

" I wonder if a bleeding stroke is what made her fall in the first place?"  This is the million $$ question.  I suspect it but can't prove it.

Thanks for your input.
Helpful - 0
690060 tn?1247841741
NTB
hi, just some thoughts:

- for assessing home INR monitoring, I'd look to the experience of the Netherlands - where the gov't pays for it and so it is extensive. I believe their results were very good.

- the key to eliminating diet's effect on warfarin is to be consistent with the diet. Warfarin is a vitamin K antagonist, and many foods have vitamin K, e.g. Also research drug interactions.

-methyldopa for BP?? does she have some special need to take that outdated and dangerous drug for BP?

- determine if being on HTM med is identified as a risk factor, even of BP is thereby controlled

- the risk of bleeding.is meant to be on its own. In other words, rather than stopping warfarin, I'd try to insure against further falling.

-speaking of spontaneous bleeding, I'd look at how apixaban fared in the thromboprophalactic trials with orthopedic surgery patients. If I recall correctly, rivaroxaban and dabigatran did better.

About the doc on further tests, I think most docs might say the same. If the test results won't change treatment, then it's mainly a matter of curiosity.

-warfarin does take a day or two to have full effect, and that's why they bridge with heparin if necessary in acute situations. OTOH, overdose with warfarin can be treated by administering  vit K.

- I wonder if a bleeding stroke is what made her fall in the first place?
Helpful - 0
1069105 tn?1256700412
Thanks Jerry.

Do you monitor your INR @ home ?  I had seem ad for home monitoring INR device.  Is that accurate & reliable?

My Mom's doctor did not give us any detail of her AF condition non would he entertain our request of additional testing.  My Mom doesn't exhibit any AF symptom.  Only info we have is her ECG.  It is very difficult to get second opinion in Singapore (it is a SMALL island, all doctors know each other)  Only risk factor she has is age & hypertension that is now under controlled with BP medication.  Her BP is 110/60.

Her INR is measured at 3.5 when she is admitted to the hospital.  I had asked her to ask her Cardiologist for her INR # every visit.  I understand other supplement or even diet can change the INR #.  Her Cardiologist is not even addressing this aspect.

I speculate, before the accident (fell), she is taking more Warfarin. I have her dosage chart that she used before the fell, she take 1 tablet daily & an additional one tablet every 4th day.  Don't know what is the mg/tablet because it is unmarked, but my understanding is min. is 1 mg, so that would mean min of 8 to 9 mg/week vs currently she is taking 3 tablets/week at 1mg each, means 3 mg/week.  I also understand that when you start the Warfarin treatment, the dosage is slowly build up to reach the target INR.

Thank you & wish you all the best.
Helpful - 0
612551 tn?1450022175
COMMUNITY LEADER
I take 5 mg of Warfarin a day for my AFib.  I also take a low dose aspirin.  I manage to maintain a INR between 2 and 3, the desired range.  That means while I have "thinned" blood, my bleeding risk is managed by keeping the INR below 3.  

I have permanent AFib, that is I have constant AFib, not just episodes from time-to-time.  I am 70 years old.  

Aspirin does not give sufficient protection, thus I am also on Warfarin, and a lot higher dose than I understand you to say your mother is taking.  

The conventional theory to my understanding is if the clot/stroke risk is high (several factors:  I have at least two: age and constant AFib) on is better off controlling that even if it does increase the risk of bleeding.

One would need to know what the INR was when your mother had the "bleed out" to have any fact-based opinion on the use of 1 mg of warfarin a day... and to that find out what here INR is when taking 1 mg a day, and can she control it.  Some people for reasons of diet or other (not know to me) reasons have an INR that "jumps" around.
Helpful - 0
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