Coumadin or no Coumadin

[paceman]

Thank you in advance for your help. First I'll give a quick history: I'm a 37,male, 6', 220lbs., caucasian
1. Open heart at age 4 for ASD
2. Two Catheter Ablations for A-tach. Both were unsuccessful and left me with a pacemaker because I went in to complete heart block.
3. Open heart surgery at age 35 for Sinus Venosus Defect.
4. Maze Procedure performed during last open heart surgery. Successful; no A-tachs since.
4. Left Atrium measures 5cm
5. Moderate mitral valve regurgitation
6. Dilated Coronary Sinus
7. Current medications: 325mg of Aspirin daily, 5mg Lusinopril
8. Avg. BP 130/82

So here's the big question; at my last pace check, 2 episodes of A-fib were found. One lasted only 4 heart beats and the other lasted 30 seconds. One was in Jan.08 and the other in May of 08. My Ep Dr. has recommended I start Coumadin due to the A-fibs. I wore a monitor for 21 days and nothing registered. Although, I'm usually a very good patient, Coumadin seems like an overkill for only 2 very small episodes. What do you think? How long does Afib have to last in order to cause a stroke?

Would it be unwise for me to take a wait and see approach? I thought maybe I can get a pace check every 3 months and see if the Afibs become more regular?

I'm very active with two young children. Although I do not want to suffer from a stroke, I wonder if Coumadin is the best option for me. I should also mention that I am asymptomatic. I never even felt my A-tachs either.

Thank you again and I look forward to your response.

[Michael J. McWilliams, M.D.]

That is quite a history for a young man.

I agree that  your atrial fib episodes are very short and I typically do not start coumadin for 30 seconds of atrial fib one occassion.  The traditional risk factors for stroke with atrial fibrillation are:
1. age greater than 75
2. hypertension
3, diabetes
4 heart failure
5 history of stroke/tia.

You are treated for your blood pressure with lisinopril so technically you have high blood pressure.  You have one risk factor for stroke according  to the atrial fib guidelines and therefore have the choice of coumadin or aspirin.  It might be worth asking your doctor why they feels so strongly about taking coumadin -- there might be a good reason, but you don't fit the traditional risk factors.  Ultimately, this is just information and the decision is up to you and your doctor.

I hope this helps.

[BABlocker]

Having two episodes of only seconds in length does not warrant Coumadin, per the 2006 AHA guidelines, with link included below. At your young age, and with relatively few risk factors, and with your episodes so infrequent and short, I would refuse Coumadin at this time. Of course your ASA is quite appropriate and should be continued. My EP and Dr. were concerned if the afib lasted longer than 24 hours as clot formation is more likely with longer episodes, but my episodes were 1 hour or less; I was maintained for months on ASA alone. At one point, last December, I went into persistent afib and decided myself to resume Coumadin even when my EP maintained I was a low stroke risk, having well controlled hypertension as my only risk. I have just undergone a 3rd ablation and hope to cease Coumadin in the relatively near future.

Here is the link:
http://www.medscape.com/viewarticle/543645_2.

Good luck to you!

[paceman]

Thank you for your response. So far I have refused the Coumadin. Let's see if this Doc agrees. Good luck w/your ablation. Is this your 3rd because it keeps coming back? I had two but was finally successful w/the Maze procedure.

[zoran66]

A related discussion, coumadin yes or no was started.