Patients who have been diagnosed with atrial fibrillation (AF) and who are above the age of 65 or have co-morbidities such as high blood pressure, Diabetes, heart failure or vascular disease have a 5-fold higher risk of suffering strokes. A significant proportion of the strokes are believed to be as a consequence of blood clots which have formed within the heart and then been dislodged and travelled to the brain blocking vital blood supply to parts of the brain. Certain anticoagulants such as warfarin and the DOACs have been shown to reduce the risk of strokes in AF by 60%. It is believed that they exert this benefit by delaying the clotting of blood and therefore reducing the risk of clot formation within the heart. It is
therefore recommended that patients who have been diagnosed with AF and who are at a higher risk of strokes take anticoagulants lifelong.

The seatbelt analogy

Taking anticoagulants in AF is like wearing a seatbelt when we get in our cars. We do not wear seatbelts because in some way they improve our quality of life. We wear them because they could potentially save our lives or reduce our chances of coming to harm. Similarly, anticoagulants do not have a measurable impact on how we feel. They simply reduce the likelihood of blood clots forming within the heart. We take them because they could improve our lifespan, not our quality of life.

Many people suffer from paroxysmal AF which means that their AF can come and go episodically. Such patients often ask whether they can take their anticoagulant only when they are in AF. I advise against this for several reasons.

1) A significant proportion of patients can also have episodic ‘silent’ AF which means that they may be in AF at times when they don’t even know about it. Usually the episodes of AF that are felt by patients is when the AF is accompanied with a fast heart rate. However episodes of AF which are not accompanied with a fast heart rate may be asymptomatic to the patient.

2) Several studies of patients with implantable monitors have shown that there is no good correlation between the episodes of AF and timing of strokes. Once you have been diagnosed with AF, the risk stays regardless of whether you remain in AF or whether the AF goes away. The risk of stroke is dependent on your CHADS2VASC score which is based on age and the presence or absence of co-morbidities. As age is an important determinant of risk, the risk can only ever go up as we can only ever get older.
Finally many patients ask me whether they could use a ‘natural’ anticoagulant such as Ginger, Garlic, Motherwort or Nattokinase. Again I recommend against this. To understand this we should go back to the seatbelt analogy. We wear seat-belts because somewhere there has been reliable research that has been undertaken which shows that certain types of seatbelt reliably reduce the risk of harm or death in the eventuality of an accident. We can not assume that every single contraption called a seatbelt will offer the same protection and therefore car manufacturers should only use those makes of seat-belt which have the evidence base supporting their claim. When it comes to anticoagulants, Warfarin and the DOACs have been extensively studied in hundred of thousands of patients and been found to reliably reduce the risk of strokes by 60%. The natural alternatives do not have this weight of evidence to back their routine use.

In summary:

Anticoagulants are recommended because they reduce risk of strokes

The risk is dependant on age and co-morbidities rather than the presence or absence of AF

Anticoagulation should be taken for life

Natural anticoagulants do not have the same weight of evidence in terms of stroke prevention as Warfarin or the DOACs


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