This section is provided by one of our medical consults:
Dr. Teresa Dean, M.D.
On-Site Physician at Dunwoody Pines
Preventing Stroke and Heart Attack
Consistently over the years, one of our biggest targets in medicine has been preventing strokes and heart attacks due to the large number of people affected by these disease processes and huge effect they can have on quality and length of life.
Though there are several classes of medications aimed at reducing the risk of both stroke and heart attack, there has been a recent flurry of information and marketing surrounding anticoagulants (blood thinners) bringing this to the forefront of conversation and an important and timely health topic to discuss.
*Please note that ALL anticoagulants carry the risk of increased bleeding time and therefore the danger of life-threatening internal or external bleeding. It is always important to discuss with your physician the risks and benefits of these medications for your personal medical history and goals.
What are Anticoagulants and Why are there so many?
Anticoagulants are any medication which intereferes with any portion of the clotting process, this includes at least a dozen oral medications such as Aspirin, Plavix, Warfarin, Pradaxa and Xarelto, as well as five regularly used injectable medications generally used in the hospital. The variety of medications is not just a battle between pharmaceutical companies; in this case, many of the anticoagulants have been proven to be particularly effective for one given disease as either primary or secondary prevention.
Primary prevention is the goal of reducing the first time occurance of a disease for a person with any risk factors. Secondary prevention is aimed at reducing the risk of recurrance of an acute incident in a person who has already had signs of the disease, such as preventing a second heart attack.
• Heart Attack Prevention: The primary prevention is low dose aspirin for anyone with any risk of coronary artery disease including advanced age or history of hypertension or diabetes. Preventing a recurrant heart attack is standardly done with aspirin plus plavix for a given duration of time, depending on the initial treatment for your heart attack and your risk factors of recurrance versus your risks of bleeding.
• Stroke Prevention: Again the primary prevention is low dose aspirin for anyone with risks for stroke. The best data for preventing recurrant strokes though has been for Aggrenox, a medication that combines aspirin and dipirymidole.
• Venous Thrombus (DVT) Prevention: The key to preventing DVT’s and pulmonary emboli (PE) is mobility! If a DVT or PE does occur, the standard of treatment is 6 months of warfarin or xarelto or indefinite treatment if risk factors persist for recurrence.
Which anticoagulant is right for me if I have atrial fibrillation?
➢ Warfarin: Inhibits Vitamin K recycling, due to its function through vitamin K the ability to control its therapeutic level varies with diet, antibiotic use, infections and many other drug interactions that affect Vitamin K levels in the body.
• Warfarin has a higher intracranial bleed risk than other newer anticoagulants approved for stroke prevention in non-valvular afib, predominantly due to its difficulty maintaining a goal therapeutic level.
• Bleeds due to warfarin are potentially manageable with Vitamin K injection, unlike the nonreversible effects of other anticoagulants in this class. It is important to note that despite this fact overall fatal bleeds were lower in studies comparing warfarin to the below newer medications.
➢ Pradaxa: Direct thrombin inhibitor (not related to vitamin K, therefore not variable with diet)
• Embolic strokes occurred at 1.11% per yr versus 1.66% with warfarin for patients with an initial average risk of stroke of Chads score 2.1. Though GI bleeds occurred 1.5 times more often with pradaxa than warfarin, there were 2.5 times less intracranial bleeds.
➢ Xarelto: Direct Factor Xa inhibitor (not related to vitamin K, therefore not variable with diet)
• Embolic strokes occurred at 1.7% per yr versus 2.2% with warfarin for patients with an initial average risk of stroke of Chads 3.4 with half the risk of fatal bleeding compared to warfarin users in the study.
➢ Eliquis: Direct Factor Xa inhibitor (not related to vitamin K, therefore not variable with diet)
• Embolic strokes occurred at 1.27% per yr versus 1.60% with warfarin for patients with an initial average risk of stroke of Chads 2.1 with 0.4 risk of intracranial bleed compared to warfarin and minor reduction of all other bleeds.
It is very important to note that each of these newer medications have been compared only to warfarin respectively, they cannot be directly compared to each other. It is important to have a critical review of the specific profiles of the medications with your physician for your specific risks and health goals.
Dr. Teresa Dean, with Assisted Health Partners, provides on-site primary care medical services. Look for more on your medical topics of interest in live seminars here in your community. For more information, feel free to contact 404-633-4838. We look forward to helping you maximize your health.