DOAC use for short Atrial Fib episode in 93 yo active male

I state up front that I am not an expert, nor do I practice medicine. I just read a lot, and I try to internalize what seems to be common learning uttered and posted by others with arrhythmias who have had treatment.

A CHA2DS2-VSc score of 2 is what tells the physician counselling the patient that they should be on a DOAC. Your dad can always refuse if he is willing to bear the risk of a stroke which is typically close to 6 times higher than a typical patient without arrhythmia. I dunno, if I were his age, otherwise doing okay, not expected to live another three years or so (which might be realistic if untrue), and my fibrillating rate is consistently less than 80, I would be tempted to opt out of a DOAC. But, if I liked living, could reasonably expect to live another 6-8 years (which might be quite reasonable for him), and I was in and out of AF, say twice a week for about an hour or more, I would take the DOAC. But that's just me. If my rate were higher than 110 when in AF, I would definitely take the DOAC....if I knew I was good for another four years or more. On the other hand, if I were generally feeble, not enjoying life a great deal, lonely, sore much of the time, and probably within a year of a natural death.....................I would hold up my hand and say fuggeddaboudit.

That's a long and convoluted way of saying he should inform himself of his risk, and marry that to his will to live and his apparent life expectancy. He should probably be on it, but it brings risks such as when falling and getting a brain bleed. Not taking it might mean bedridden for six months until he dies from despair, but after a catastrophic stroke.

@mhutch527 I can only write about my own experience, I have declined anticoagulation for 10 years. I have had episodes roughly once/year lasting 45 minutes to 7 hours (usually less than 2 hours). In 2015 my cardiologist wanted me on an anticoagulant. He later told me he thought I was right in declining. He said he believed they were "overmedicating" people.

My other cardiologist came into my hospital room after a bad episode and told me to "go home and forget it happened." This past year I finally found a doctor who is in the middle of these two approaches!

My current CHADS score is also 2. I finally got "pill in the pocket" Eliquis but have not had to use it.

Doctors have protocols and a score of 2 means anticoagulation is suggested. I believe they may feel more liable if they don't prescribe.

I did a month of a monitor and had a few moments of afib, atrial flutter, tachycardia and bradycardia. I still don't take any meds daily and have taken diltiazem maybe 3 times in 10 years. With afib my heart rate goes up to 190+ so I do feel it.

I often suggest the book "The Afib Cure" by cardiologists Day and Bunch. It has info on avoiding or stopping meds, but also on various med regiments and ablations. I take magnesium, drink low sodium V-8 for potassium, never eat late, and never recline after eating.

It might be helpful if your dad has a way to monitor- a Kardia or Smart Watch. So far he is not having any hidden afib other than that 11 seconds, in a month's time. If he has high blood pressure, weight issue, or diabetes they can be concerns but with his CHADS at 2 it sounds unlikely.

I am just another patient with an individual situation. We are all different. It has helped me to get more than one opinion, read and learn, and go to the cardiologist with notes!

Well @gloaming and I posted at the same time with very different perspectives. Both have validity. I have a lot of respect for @gloaming but I have also seen my mother on Coumadin and what happens with falls, as well as micro bleeds in the brain. I carefully managed her INR with the clinic. There are newer anticoagulants, obviously. It is truly a risk/benefit decision.

If your father can monitor at home and assess the frequency and duration of afib, then short term anticoagulation may be a possibility. He can ask a doctor about this. Again, I recommend "The Afib Cure" though I think the title is a bit misleading.

Thank you for your response @gloaming. You have brought up excellent points and the last paragraph is a great summary he and I will discuss further.

@windyshores thank you for your response. I haven't heard about the "pill in the pocket" Eliquis. That is a great suggestion for him to get. He also has a smartwatch and we are going to add the Atrial Fibrillation monitoring ability.
I also will get "The Afib Cure" by Cardiologists Day and Bunch. We have him on magnesium for sleep. Will look into your other suggestions too!
I so appreciate this mayo clinic discussion group and everyone's help.

@windyshores, like your mother, he has had 4 significant falls this year. Each required an emergency room visit. Thankfully he wasn't on any anti-coagulation medication. It is truly a risk versus reward-situation. Thanks again.

Anything I wrote needs to be discussed with a doctor! I have to admit I find doctors who follow the protocols I prefer 🙂 My perspective is based only on personal experience so you can take all the opinions here and come up with questions for the doctor you choose.

My father who did NOT have Afib but did have 2 clotting factors which increased his risk of clots many fold. He had a history of TIAs, or what is referred to as a mini strokes. So he was on warfarin (pre -DOAC) for the clots. So he also had a history of falling due to pinched nerve in lower back also known as spinal stenosis. He also had poor safety judgment. He died age 86. He was in otherwise great health. But he was recovering from a fall and had almost completely recovered. He was ready to come home from rehab. But he stood to void his bladder without help and he fell backwards and hit his head. He was sent to the ER of a very large university based hospital where I worked. He had a brain bleed but they thought that he had enough space in his skull for a mild bleed. Older folks often have some atrophy in the brain hence they thought they could let him bleed thinking he would clot before any issues arose. About 8 hours later he suffered a seizure. After a stat Cat scan it revealed he had bled too much and was getting pressure on the brain. So they immediately reversed his warfarin using plasma. He was admitted to intensive care. He began to recover with mild cognitive improvement daily. Then a week after the fall due to his clotting factor disorder he developed clots. I received a midnight phone call and my father was in respiratory distress and was critical. I had to make the decision to DNR my father. I am crying as I write this. This was his 3rd brain bleed in 7 months. The last brain bleed resulted in coming off blood thinners thus he died of pulmonary embolisms from his clotting factor disorder. He was caught between a rock and a hard place. He was gone before I could get to the hospital . I have inherited one of his clotting factors. If I had both it would raise my risk higher and I have had 2 ablations for Afib. So as I read this story about a 93 year old active man with a risk of falling and a single Afib event of very short duration I think this is a balancing act on deciding what to do.
If it was me I would want more reason to be on blood thinner than a single short duration Afib event. I am presently on DOACs as I am post ablation X 4 months. That said whether he takes DOACs or not I would highly recommend that if he is not in physical therapy for strength and conditioning he should be. The literature is overwhelming that strength and conditioning significantly helps geriatrics reduce their risk of falls. This risk reduces bleeding and broken bones and generally improves quality of life. I would also stress learning to have good safety judgment when ambulating. These last areas are my and my wife's areas expertise in physical rehabilitation. We have a combined 75 years experience in this field and have treated many thousands of people all to improve their quality of living. We have seen and experienced a lot of medicine in our lives: both good and bad medicine. I was a Certified Orthotist who designed and made braces for people with neurological and or orthopedic problems and my wife was a geriatric physical therapist. Oh speaking of safety judgment I am 77 and am going to go out after I write this and cut firewood. 🙂 So go figure. I am extremely careful and have cut firewood most of my adult life.
One last thought is to get a Kardia device and he can check his Afib status all day long to see if he can replicate it.

@harveywj so sorry for your father's (and your) experience. (I could relate thinking of my mother.) This story perfectly illustrates the "rock and a hard place" many of us find ourselves in, and the need to balance risk and benefit in considering anticoagulation.

After one 11 second record of afib in a month, it would seem that continued monitoring at home will help with decisions. If that pattern continues, discussion with a doctor on waiting on anticoagulation might be helpful, especially in the context of a CHADS score of 2. Or "pill in a pocket."

I continue to be offered anticoagulation by some cardiologists, in the ER and the hospital, but the EP I recently saw immediately suggested PIP for my infrequent (but dramatic) afib episodes. I feel caught in the same dilemma!

PT and OT can be helpful but I also rely on tai chi - a few times a week and at home. It helps with strength, balance and alignment and is relaxing. Stress is certainly a contributor to arrhythmias so that is another benefit.

I use a Kardia to document afib. If a person doesn't feel it, that might not be the best way to monitor though.

Windy,
Your story is a perfect example of how to find a place to walk that fine line. I do not like one answer fits all people. Before I had frequent (monthly events that lasted from hours to 1-3 days) I always carried DOAC in my pocket. If I went into Afib I took it immediately. If converted in a matter of hours my EP was satisfied with taking just one. If it lasted for days then I did 30 days of eliquis. But then when Afib became more regular I just decided to say on it. But I'd sure give you my vote for what you are trying to do. I literally had a verbal fight with a PA who tried to force me to take DOACs. I kicked him out. Tai Chi is a great method to improve a person over all physical well being. I only mention physical therapy because 1. that is where all the studies are done 2. It is very easy to find a clinic that follows geriatrics in a special program thus making it easier for those with out your abilities to find a place to go.

I am also a cancer survivor. Age 53 I was diagnosed with prostate cancer. I saw 4 different urologists who all gave me from 5 to 10 years to live unless I was treated for it immediately. That was 2001.
I found a prostate oncologist and had multiple tests done bi-yearly and waited 6 years before I was treated. I am now 24 years since my diagnosis and 17 years since I started treatment which lasted 18 months. I am still in remission.
I am very cautious about when I am seeing an MD. I don’t jump and run at the first person who says you gotta do this or die. I've seen and or experienced 1st hand too much bad medicine. I am usually am pretty good a finding good medicine.
Cardio stuff is way out of my area of medicine but I know how to judge clinicians when I meet them and I know how to study and do research to at least give me a basic understanding of whatever I am dealing with .
But even then is so much one can do and then they have to a shot and hope for the best.