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

That's a tough one, trying to decide the appropriateness of an anticoagulant for an elderly gentleman with a history of one short-lived A-fib event found on a month long monitor report showing no other A-fib events. I could see where a cardiologist might be looking to CYA in prescribing a DOAC to this patient, but not sure it's a situation, given the guy's history, where it's really needed (???)

There is a similarity between this guy's history and mine, regarding infrequent bouts of arrhythmias, including in my case, A-flutter. I've had a long history of SVT- determined later to be atrial tachycardia, over the years, which has been well controlled by metoprolol. Then there was the day ( in 2015) where I woke up in the wee hours to that fluttering feeling in my chest, accompanied by a slight light-headedness and shortness of breath. I did everything I could to stop it, but nothing helped and about 4 hrs later we headed to the ER where I assumed an adenosine IV would at least slow things down. When we got to the ER, the nurses informed me that what I was experiencing was A-flutter, with a heart rate around 140. As I settled into one of the bays, the tachy stopped on its own and I went back into NSR. The ER doc insisted on admitting me to see a cardiologist, and that is when I met the cardiologist I still see to this day. He changed some of my medication, and discharged me, with instructions to make an appointment to see him.

Even before that visit, this cardiologist ordered a 21 day monitor to detect any additional episodes of A-flutter or A-fib, but the results showed basically NSR, no A-fib or flutter. The cardiologist informed me that they monitored people with a history of A-fib/flutter, but he did not prescribe an anticoagulant at that time. He instructed me to go to either the office or the ER in the event I had another episode, and they would document the event, if it was A-fib or A-flutter he would prescribe an anticoagulant then. At that time I was 68 yrs old, and my CHA2DS2-VSc was probably 2.
I had additional episodes of tachycardia in the years following the above episode, they were fairly short lived and additional monitoring showed these events to be SVT not A-fib, so an anticoagulant was not indicated for me. The increasing number of tachycardia episodes were controlled with higher doses of metoprolol, which I continue to take to this day and have always tolerated it well.
Over those years, however I developed bradycardia in addition to the tachy and long story short, I had a pacemaker implanted in 2019. Well, most pacemakers these days come with remote monitoring capability so my cardiac monitor ( to which the pacemaker transmits data periodically) transmits the pacemaker/cardiac activity to the manufacturer's website which is accessed by the pacemaker clinic in my cardiologist's practice. So.. now they see all my cardiac activity, including tachycardia events and much more. The cardiologist informed me that they were seeing a few short runs of A-fib ( each lasting only a few seconds) on those monitor reports, and that while he didn't feel the burden and duration of these events warranted starting an anticoagulant, that they had to watch it. Then about 6 months later, they contacted me, informed me of a number of A-fib events lasting several hours each ( I wasn't even aware of them!) they'd seen on the monitor, and instructed me to come into the office to see the doc that day. This was when the cardiologist told me it was time for the anticoagulant, and I started on Eliquis. At that time, the CHA2DS2-VASc score was 3 ( I'd had a minor incident believed to be a TIA and they were taking no chances). I was scared I'd bleed out on an anticoagulant, but figured this was the same doc who could have started the anticoagulant as early as that first A-flutter incident when I met him, or during the times they saw short A-fib runs on my pacemaker reports, but didn't, so if he said now was the time for an anticoagulant, I had to believe him. Fortunately, I've had no adverse effects from the Eliquis, not even excess bruising.
My A-fib events are still paroxysmal, mostly lasting just a few seconds, and there can be 6 months worth of pacemaker reports that show any tachycardia is SVT, not A-fib. I've asked the cardiologist about discontinuing the Eliquis, and his last comment about that was "If I were a betting man, I"d bet that A-fib will be back, and I think you know that too". There's no arguing with that, now with a CHA2DS2-VASc score of 4 at age 77- not counting the female score and a strong family history of strokes, as well as additional episodes of A-fib ( I got some of them on an Omron blood pressure EKG machine- has a Kardia mobile attached to it) recently. That and potential new cardiac diagnoses ( possible pulmonary artery hypertension) that warrant anticoagulation under some circumstances, I must admit I am better off with the anticoagulant.

I try to be careful about activities which might put me at risk for falls or bad cuts,so far so good. Everyone's decision is his/her own, and people's situations are different, and the calls may not be easy to make, but that's my experience. Again, I have to express my appreciation for the cardiologist who was so conservative at making the call for an anticoagulant in my case.

Mary,
Thank you so much for sharing your story of your health, and atrial fibrillation journey in particular. It helps to hear other people's experiences so much.
It is good to hear you have done well on Eliquis. It supports that atrial fibrillation episodes, even if minimal initially, can increase over time. We will set up the atrial fibrillation monitor on his smartwatch. This isn't the best monitoring, but will give us some additional information. If the events begin increasing in frequency as you did, then we can look at him starting Eliquis.
Like you, we have no interest in him having a stroke. It is such a balancing act.
Thank-you again. Appreciate you taking the time to share your experience with atrial fibrillation and Eliquis.

Margo

Harvey,
Great insight. I appreciate your approach to your A Fib situation.
I also agree with your cautious discernment of the advice of medical providers. Wisdom comes from the counsel of many. As your treatment for prostate cancer shows. The internet, if used wisely, and sites like this can inform us on health care dilemmas.
You are right, at some point, you have to make a decision and hope for the best. Rarely is there one best and only correct decision.
Thanks for your comments.
Margo

Agreed we will run our thoughts by his doctor. I appreciate your personal experiences though.
You are correct, these opinions lead to good questions to discuss with his doctor.

Margo

That sounds like a good plan to me. With any luck your Dad's A-Fib will remain minimal for a long time ( seems as though mine has, so I know it can), enough not to need anticoagulation. But you'll be right on top of any possible episodes that could occur with the monitoring on his smartwatch, and can deal with any issues that arise ASAP.

My best to both you and your father. Mary

Thank you Mary!