Author’s Note: ‘Ron’ is an actual patient; however, I changed the details of his case to preserve his privacy. Nevertheless, the story of his success in preventing strokes is true. If you or someone you know has a similar story to Ron’s, please consult a healthcare professional.
Ron was 79 years old when he visited me, complaining of heart palpitations. He had a history of high uric acid levels and a type of irregular heartbeat called atrial fibrillation (AFib), which he had had for about two years. I checked for other health issues that could increase his risk of blood clots but found none. Even though he had a moderate risk of stroke according to some scoring systems, he was not taking any blood thinners. When I tested his heart's electrical activity, I confirmed the irregular heartbeat, and his blood work showed slightly impaired kidney function and signs of possible blood clotting. A heart ultrasound showed no significant problems, but it did reveal a large blood clot in his heart's left atrium.
The Risk of Strokes
AFib is a common arrhythmia characterized by irregular and often rapid heartbeats originating in the heart's upper chambers (atria). It is prevalent in older adults because advanced age is a significant risk factor. Over time, the likelihood of developing AFib increases, and it is estimated that nearly 9% of people over the age of 65 have this condition.
The link between AFib and strokes is well-established, especially in older adults. AFib disrupts the normal flow of blood through the heart, leading to the formation of blood clots in the atria of the heart. These clots can then break loose and travel through the bloodstream, eventually reaching the brain, where they can cause a stroke by blocking blood flow to different part of the brain. In fact, AFib is associated with a five-fold increase in the risk of stroke, making it one of the most significant risk factors for stroke in older adults.
What makes AFib particularly concerning in older adults is not just the increased risk of stroke but also the potential severity of these strokes. Older adults are more likely to have other comorbidities, such as high blood pressure, diabetes, and vascular disease, which can exacerbate the effects of a stroke and increase the likelihood of disability or mortality.
Managing AFib in older adults requires a multifaceted approach aimed at reducing the risk of stroke while considering the unique needs and vulnerabilities of this population. This often involves a combination of lifestyle modifications, medication, and sometimes invasive procedures.
One of the treatment's primary goals is to prevent blood clot formation. This is typically achieved using anticoagulant medications, such as warfarin or direct oral anticoagulants, which help to thin the blood and reduce the risk of clot formation. However, prescribing anticoagulants in older adults can be challenging due to concerns about increased bleeding risk, particularly in those with frailty or multiple co-existing illnesses. Careful assessment of the risks and benefits is essential when deciding on anticoagulant therapy in older adults with AFib.
In addition to anticoagulant therapy, other interventions may be necessary to manage AFib in older individuals. This can include medications to control heart rate and rhythm and procedures such as catheter ablation or electrical cardioversion to restore normal heart rhythm. However, these interventions also carry risks, particularly in older adults with underlying health issues, and must be carefully considered on a case-by-case basis.
Beyond medical interventions, lifestyle modifications such as maintaining a healthy diet, engaging in regular physical activity, and limiting alcohol intake can play a crucial role in managing AFib and reducing the risk of stroke in older adults. Moreover, regular monitoring and follow-up with healthcare providers are essential to ensure the condition is adequately managed and complications promptly addressed.
Ron’s Treatment Plan
It was hard to check Ron’s blood regularly because he was in a hospital for reasons related to his dementia. Some studies showed that new blood thinners like dabigatran and rivaroxaban could dissolve blood clots in the heart's left atrium. I chose Eliquis for him because of his age and kidney problems; I believed it would be tough to control his condition with a traditional blood thinner like warfarin.
Eliquis is a type of blood thinner that directly targets a specific factor in the blood. The typical dose for someone like Ron would be 5 mg twice a day, but due to his age and kidney issues, we gave him a lower dose of 2.5 milligrams twice a day.
After two weeks of taking Eliquis, the ultrasound of Ron’s heart showed that the blood clot was getting smaller. By four weeks, it had shrunk even more. He kept taking Eliquis for another 11 weeks, and the clot was much smaller by the end. Tests also showed no signs of new strokes or bleeding while he was on the medication. Ron followed up with me for several months without any issues or problems.
Currently, blood-thinning medications called novel oral anticoagulants are becoming increasingly popular for stroke prevention. Studies have shown that Eliquis is more effective than warfarin in preventing strokes while causing fewer bleeding issues. Eliquis is rapidly absorbed by the body and its effects last relatively long. It is also less likely to be affected by kidney problems or age, making it safer for older patients.
Recent studies have also found that other novel anticoagulants like dabigatran and rivaroxaban can dissolve blood clots in the heart and veins. These medications enhance the body's natural ability to break down clots. For example, rivaroxaban has been shown to make clots more vulnerable to enzymes that dissolve them, which helps to clear them away.
Managing AFib in older adults requires a comprehensive approach considering the complex interplay of age-related changes, comorbidities, and treatment considerations. By carefully balancing the risks and benefits of various interventions, healthcare providers can help reduce the risk of stroke and improve outcomes for older adults with AFib. If you or anyone you know has AFib, please consider consulting a healthcare professional regarding medications for stroke prevention.
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