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Preventing Blood Clots (Drs. Bartholomew and Evans 5/1/13)

Wednesday, May 1, 2013 - Noon


There are many conditions that put someone at risk for blood clots, which can lead to stroke or even death. Dr. John Bartholomew, Section Head of Vascular Medicine and vascular medicine specialist and Dr. Natalie Evans answer your questions about blood clotting disorders, risk factors, medications and treatment options.

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Blood Clots – General

Blossoming: What causes blot clots, What are the symptoms? And what is the remedy?

Natalie_Evans,_MD_: Many things can cause blood clots, and the symptoms depend on the location of the clot, among other things. The treatment depends on the type of clot, its location, and the circumstances in which it happened.

John_Bartholomew,_MD: we generally consider blood clots to be hereditary or acquired.

Common hereditary causes include prothrombin gene mutation G2021A and Factor V Leiden. Other hereditary causes include protein C, S and antithrombin deficiencies. Acquired conditions include recent surgery, immobilization, fractures, trauma, birth control pills, hormone therapy and pregnancy. The symptoms can range in leg swelling, redness or discoloration and pain if the clot is in the leg. If the clot is in the lungs, the patient can have shortness of breath, chest pain, passing out or coughing up blood.

Factor V Leiden

cjf: I am a 65 year old female with Factor V Leiden from one parent. I have not had a blood clot so I am not on a blood thinner. I am taking Lovenox injections for 28 days due to gallbladder surgery. I also have UC and I am due for a colonoscopy in Oct. My question is will I need to do the Lovenox injections for 28 days after the colonscopy and will I be safe in stopping my aspirin 6 days before the colonscopy? Thank you so much for this information.

Natalie_Evans,_MD_: You may wish to discuss your case with a specialist in blood clots. In general, for patients with only one copy of the factor V Leiden gene and no history of blood clots, I do not treat them very differently from patients without factor V Leiden, but without knowing further details of your case, it’s tough to give you specific recommendations.

John_Bartholomew,_MD: I would not recommend lovenox injections after the colonoscopy given that you only have factor v Leiden and no other risk factors for blood clots. There is always an increased risk of bleeding if there were biopsies.

I would make sure you discuss stopping the aspirin with your gastroenterologist. Some doctors hold aspirin longer than others.

Sue in WDC: Yikes, blood clots... Several years ago, one of my sister's sisters-in-law found out she had Factor V Leiden, an inherited clotting disorder. She had a successful procedure to remove two pulmonary emboli and considers herself lucky. She takes Warfarin and will for the rest of her life. Subsequently, other family members were tested for Factor V -- some have it and some don't. Apparently, my niece won't be tested until she's pregnant with her first child. If she does have the gene, will she have options besides Warfarin? Would any of the novel anticoagulants be effective? Finally, how dangerous is the condition and what does it mean for everyday life? Thank you for taking my question.

John_Bartholomew,_MD: First of all we do not consider Factor V Leiden a major risk for blood clots except for women who are pregnant, on BC pills or hormone replacement therapy. We do not normally treat patients with Factor V Leiden on blood thinners for the rest of their life. If they had a blood clot that was provoked, for example if your sister's sister in law who has factor v Leiden developed the blood clot during pregnancy or was on hormone therapy such as HRT or BC pills, or had a recent surgical procedure or trauma, or other precipitating condition, we do not recommend lifelong anticoagulation. If her blood clot was unprovoked, then we would consider life long anticoagulation.

Tom724: I have clots in my leg diagnosed as F5 Leiden. I've been on Coumadin & Arixtra, and neither have dissolved the clots. Should I consider having vein scraped?

Natalie_Evans,_MD_: Anticoagulants do not dissolve blood clots. They prevent clots from growing and new clots from forming. If you do not have symptoms from the clot that remains in your vein I would not recommend any intervention to the vein.

Blood Clots and Hormone Replacement Therapy/Birth Control

nmunchkin101: I am 27 y/o and developed 6 PEs in March after having a fibroid removed. I have been on the same oral birth control for 8 years. The combination of surgery and being on hormone based birth control were the leading factors in my developing PEs. I was told I could never go back on a birth control that has ANY hormones and that my only option was the copper IUD. I have not read good things about the copper IUD and don't feel comfortable with that option given the horrible side effects I've read about. Are there any other options to consider?

John_Bartholomew,_MD: There is some data that the Marena IUD is safer in patients such as yourself. Blood clots usually develop due to multiple reasons and in your case likely formed due to the surgical procedure, immobility possibly and hormonal therapy. I suggest you discuss this with your gynecologist or a hematologist who has an interest in blood clotting problems or a vascular specialist.


JennyM: I had a DVT in January. I wonder how long I will need to be on Coumadin and if there is a way to know that I can come off of it.

Natalie_Evans,_MD_: Great question, one we get all the time in our vascular medicine clinic. The amount of time you need to be on Coumadin depends on the circumstances in which you had your blood clot. Generally speaking, patients who had a DVT in the setting of surgery, trauma, or hospitalization usually need anticoagulants for about 3 months. People who have blood clots that develop out of the blue often need longer-term treatment. A vascular medicine specialist or hematologist can help decide how long you should be treated.

AmyD2342: I am a 30 yr old female who had a DVT a couple years ago. I was diagnosed with Factor V Leiden. My left leg seems swollen, discolored, and cold and can be sore at times. I try to walk and keep my leg elevated but I am nervous that I am not managing this correctly. Can you talk about how to treat or follow Factor V and also if you have any thoughts about my leg - I would appreciate any comment. Thank you. Amy

Natalie_Evans,_MD_: Another great question, two questions, really. The first is how to manage blood clots in people with the factor V Leiden mutation, and the answer is, the same way we manage blood clots in people without the factor V Leiden mutation. This inherited gene mutation is very common—seen in about 7% of the population—and can increase the risk for blood clots, but only a little bit. You should talk to a vascular medicine specialist or hematologist about your case and how best to manage.

The second question involves the long-term consequences of DVT. It sounds like you may have developed the post-thrombotic syndrome, which often involves pain, swelling, and skin changes in people who’ve had a DVT. Blood thinners do not help this condition. The best treatment for the post-thrombotic syndrome is not yet known, but in general we recommend compression stockings, elevation of the leg above the level of the heart, and exercise. If you’ve tried all these things, a vascular medicine specialist may be able to help you with other possible treatments such as physical therapy and pump devices.

lagalbraith: Eight years ago my daughter, had a DVT we believe due to family history and birth control patch. Things got better and she was taken off warfarin. Last year she ran a 10 mile race, about a week after the race, her leg felt like she had another DVT. She had an ultrasound done and they said she had another DVT. She was told that she will now be on warfarin the rest of her life, she is 34. Two weeks ago she exercised aggressively again and her leg started hurting terribly. She thought it was normal muscle pain from exercising, however the severe pain was lasting a week. She went and had a ultrasound done, this time she was told no DVT. My question is could this pain in her leg be due to the aggressive exercise aggravating the old DVT from 8 years ago that never really went away? When ultrasound was done they said the only thing they saw was old DVT.

Natalie_Evans,_MD_: It is possible that your daughter may have developed the post-thrombotic syndrome (PTS) after her second DVT. The number one risk factor for the PTS is having a recurrence of DVT in the leg with previous DVT. But in a case like this, without having seen the ultrasound from last year, it’s hard for me to say with certainty. It’s not likely that strenuous exercise aggravated the old clot, and in general we allow DVT patients to return to their normal activities including strenuous exercise. Your daughter may wish to talk to an expert in blood clots such as a vascular medicine specialist for further guidance on how to handle her situation.

John_Bartholomew,_MD: One other consideration for her blood clots would be May Thurner Syndrome. This condition leads to blood clots in the left leg and can be recurrent. I would definitely see a vascular specialist in this regards.

heinlc: I had a DVT due to an auto accident; took heparin shots and then was put on Coumadin. I have been cleared of the DVT since last September but am wondering how I will be affected by a long plane ride to Europe. As my vascular doctor said, "once you have a DVT, you will be more prone to get another." Is there anything I can take or do prior to the airplane trip that will reduce chances of me getting another DVT?

Natalie_Evans,_MD_: Look at prior responses. Generally patients who had blood clots after trauma will return to very low risk after about 3 months of treatment with anticoagulants.

dmack1106: I was just discharged from hospital with deep vein thrombosis and pulmonary embolism. I am age male age 64 and had tibia fracture from skiing 2 months ago. I live in north California coast city with minimal medical specialty. I have first meeting with my GP to discuss my condition. What are the most important questions to ask her about my condition. Is it reasonable to expect my GP to manage my care? I am thinking about getting second opinion with doctor that specializes in DVT PE, what kind of doctor am I looking for and how do I find this doctor?

Is this condition ever cured? What is normal progression? Do the blood clots go away? How do I tell if my condition is mild, moderate or severe? What is criteria to stop Coumadin? How long will I be taking this blood thinner? Am I more likely to have heart attack/stroke because of this condition? Where can I read detail about this diagnosis?

Natalie_Evans,_MD_: Most general internists have experience in treating patients with DVT and PE. However, there are a lot of misconceptions in the medical community about how long blood clots should be treated. You may wish to talk to a specialist to further discuss your case. You could see a specialist in vascular medicine or a hematologist. One way to find a vascular medicine specialist is through or .

John_Bartholomew,_MD: Most patients recover from their blood clot however there is a long term complication called post thrombotic syndrome (PTS). The best way to prevent this is to wear compression stockings for up to 2 years after your acute blood clot event. I tell my patients there are thee things blood clots do - they dissolve with time but do cause damage as mentioned above (PTS). 2. They can break loose and go to your lungs known as PE or 3. they scar the veins. As far as stopping Coumadin we normally treat for 3 months for a blood clot due to trauma and you are less likely to have a heart attack or stroke due to the blood thinners you are taking (Coumadin).

Post Thrombotic Syndrome (PTS)

JoeG: My daughter - age 20 - suffers from chronic pain resulting from DVT 2 years ago. Her care at the Mayo has revealed valves are damaged and they have offered little relief beyond Coumadin and compression hose. Her pain is increasing. Could you direct us to a Doctor who has experience with vascular valve repair. Your help is greatly appreciated!

Natalie_Evans,_MD_: It sounds as though your daughter has developed the post-thrombotic syndrome (also known as the post-phlebitic syndrome), a very common but not well known complication of deep vein thrombosis, or blood clots, in the legs. Unfortunately, because this is a poorly studied area of medicine, the treatments for the post-thrombotic syndrome are not great. Vein valve repair is not commonly done, and it’s not clear whether it is beneficial to patients with the post-thrombotic syndrome. A vascular surgeon at Cleveland Clinic who specializes in vein disease could discuss treatment options with your daughter.

John_Bartholomew,_MD: There is an over the counter medication known as horse chestnut commonly called venostat. This may be another option or you can see a pain management doctor as well if you are not seeing one.


DeeDee5: I have had 3 strokes. The doctors cannot find any clots in my heart or anywhere. The only problem is I had an MI five years ago, but my cholesterol is in the normal range now. My two younger brothers had to have stents in the main artery at ages 58 and 65, my MI was in the same artery, the widow maker. They say it must run in the family since our father died at age 50 of the same thing. I am afraid I will have another stroke. Doctors say 30% of people who have strokes never find out what caused them. I am 70, and am pretty disabled, can't walk alone or use my right hand. Any answers?

Natalie_Evans,_MD_: As you correctly point out, family history can be a strong risk factor for both heart attack and stroke. You may never know what caused your stroke. The most important thing is taking the steps to prevent a future stroke. A cardiologist, stroke neurologist, or vascular medicine specialist can help you take steps to reduce the risk for having another one.

John_Bartholomew,_MD: I would make sure you do not have high blood pressure, diabetes or high levels of Lp(a). I am assuming you are not a smoker nor chew tobacco. I also assume you do not have chronic kidney disease and you are not overweight. These are all risk factors for stroke.

Surgery and Blood Clots

fowens: I had an aortic valve replaced on May 19, 2012. On February 15, 2013 I developed a blood clot in the left leg. I understand that this kind of surgery increases the risk of getting a blood clot but would it occur 9 months after the surgery? Once you have had clot I a told you at increased risk of getting another. Is there any thing you can do to reduce the risk such as taking a daily aspirin (after I come off the 3 to 6 months of warfarin). Thank you.

Natalie_Evans,_MD_: Blood clots that develop after surgery usually occur within the first 3 months. Depending on the circumstances of which your blood clot occurred you may want to remain on long term blood thinners to prevent further clotting. You may want to talk to a specialist to get a better idea as to why your blood clot occurred.

John_Bartholomew,_MD: There is some recent data that suggests aspirin at 100 mg per day will help prevent recurrence of blood clots. You should discuss this with your primary care physician or blood clotting specialist.

Air Travel and Blood Clots

eileena: What is the real danger (or not) of frequent/long air travel relative to blood clots? There appears to be a lot of conflicting information. What is the remedy? Also, if a person has vonWillebrands disease are they less likely than others to have internal blood clots?

Natalie_Evans,_MD_: Great question! Generally, flights shorter than 8 hours or do not seem to be a risk for blood clots. Really long-haul trips, like to Australia or Singapore, may put people at risk for DVT. The best preventive measures are to get up frequently (get an aisle seat and get up at least every hour), stay well hydrated, and do calf and ankle exercise while seated. Compression stockings may be helpful, too. Von Willebrand’s disease, a bleeding disorder that is related to platelet cells and the clotting factor VIII, does not seem to protect people from DVT.

John_Bartholomew,_MD: Other tips for frequent fliers include avoiding alcohol, caffeinated beverages, drink lots of fruit juices and water during flights and do the exercises provided by the airlines during flight.

Andreea: Blood clots occur during plane travel because of dehydration, lack of movement and altitude. Do airplanes and long flights pose any risks to someone who had an aortic valve replacement surgery, or to a person suffering from venous thrombosis in the legs? What precautionary measures do you recommend? Is taking aspirin helpful?

Natalie_Evans,_MD_: There aren’t enough studies of patients with aortic valve replacements on airplanes to say for sure whether they’re at risk for blood clots from flying, so they should take all the same precautions to prevent dehydration and long periods of sitting that other people do. For certain patients who’ve had previous DVT of the legs and are not on blood thinners, I may on rare occasions prescribe a single shot of injected blood thinner prior to long-haul air travel, but in most cases I recommend compression stockings and the other measures we already talked about.

John_Bartholomew,_MD: Please see prior response above.

savtaro: Can you discuss long flights and their impact on deep vein thromboses. My husband resents when I wake him up hourly to walk, even when we are flying business class with flat bed seats. I never go more than an hour without getting up and walking and yet I know several doctors who take a sleeping pill when they board a long flight and sleep all the way through. Am I crazy or are they? FYI we are both in our seventies and my husband has had one episode of atrial fib and takes xarelto. He also has HCM.

John_Bartholomew,_MD: Your husband is already on xarelto a blood thinner - so let him sleep on long flights. He does not need to get up every hour and walk around the cabin. Patients who are more likely to form blood clots on blood thinners are those who have had previous episodes of DVT or PE (pulmonary embolism) - if you have never had a blood clot before - I would not worry as much about getting one. See our previous answer.

Antiphospholipid Syndrome (APS)

vak13: My husband diagnosed with APS and long term Coumadin. Is he at a higher risk of blood clots due to the APS or lower with the long term Coumadin for heart surgery?

John_Bartholomew,_MD: Patients with APS are at higher risk for blood clots therefore we generally recommend long term treatment if they have had a blood clot in the past. Preferred treatment for APS is Coumadin therefore your husband is in good shape.


DelNY: I have not had a great experience with Pradaxa or Xaralto for afib stroke prevention. There is a new drug called Eliquis that I believe will be coming out or is out now - is that the same type of medication and could it be possible that that drug would work for me when the others have given me side effects.

Natalie_Evans,_MD_: Eliquis (apixaban) is similar to Xarelto. These two drugs target a part of the clotting process called factor Xa. It really depends on what your side effects were to know whether apixaban might be better for you.

SharlaTx: If you are on Coumadin, you get your blood checked to make sure you are in the right range. If I switch to another agent - one of the new drugs - how do I know I am protected? Are there any tests to make sure you are in the right range?

Natalie_Evans,_MD_: Warfarin (Coumadin) requires monitoring using the INR because it has many interactions with other medications and foods. Also, people have different responses depending on their vitamin K level and certain inherited factors. Unlike warfarin, the new oral anticoagulants rivaroxaban (Xarelto) and dabigatran (Pradaxa) are very reliably absorbed in the body, so we know that if patients take the prescribed dose, they get the proper blood-thinning effect. There are specialized tests to look at the levels of these drugs in the bloodstream, but we don’t usually use the tests except in unusual circumstances like severe injuries/bleeding.

John_Bartholomew,_MD: In the studies looking at the efficacy of the new anticoagulants, one dose fits all.

DelNY: I have not had a great experience with Pradaxa or Xaralto for afib stroke prevention. There is a new drug called Eliquis that I believe will be coming out or is out now - is that the same type of medication and could it be possible that that drug would work for me when the others have given me side effects.

Natalie_Evans,_MD_: Eliquis (apixaban) is similar to Xarelto. These two drugs target a part of the clotting process called factor Xa. It really depends on what your side effects were to know whether apixaban might be better for you.

clara: I have 8 stents that have been put in the last 4 years. They in all the major arteries. None have failed. I have been on Plavix and 81mg aspirin. My concern is being on Plavix this long. Is there a risk of blood clots going off of it? The last stent will be a year old in Sept.

Natalie_Evans,_MD_: Plavix is taken to prevent blockages from reforming in the coronary arteries - most people require plavix for a limited amt of time after stents are placed. The best bet is to discuss this with your cardiologist who put the stent in how long to remain on plavix.

mutti355: I would like to know how safe pradaxa or xarelto are. I am 78 years old and am currently on Coumadin because of atrial fibrillation.

John_Bartholomew,_MD: These drugs have been FDA approved so considered safe. The data show there is less risk of intercranial hemorrhage (brain bleeding) with these drugs. There is some data that shows some patients are at increased risk with Pradaxa in elderly patients - should take more precaution. I would suggest you discuss the use of these medications with your doctor. Neither of these drugs can be neutralized if bleeding can occur. Coumadin on the other hand can be reversed or neutralized if that scenario has developed.

maidenrock: Please discuss the relative merits of Coumadin and Xarelto for prevention of strokes. I am an 80 year old woman. I've had 4 incidents of atrial fibrillation. Amiodorone has controlled the A-fib very well, but my cardiologist says it is toxic and has asked me to research Coumadin vs. Xarelto as alternatives. Thank you.

John_Bartholomew,_MD: Both Coumadin and xaralto has been proven successful in preventing strokes. Xarelto and another drug that you did not mention - pradaxa has been approved for afib. There is a third drug apixaban. All three of these drugs have been approved for use in atrial fibrillation. There is an interaction between xarelto and amiodarone. It is hard to say what would be the best drug for you. There is a warning for the use of apixaban in patients of your age. Any of the other drugs are probably acceptable alternatives especially if you stop the amiodarone. You should discuss this with your cardiologist.


John_Bartholomew,_MD: There is no antidote for xarelto at this time. Some have recommended the use of prothrombin complex concentrates or PCCs. But - there is no real antidote at this time. There is no contraindication to using a clot buster if you develop an acute stroke as per protocol within 2 - 3 hours of an event. The important thing is that you get to the hospital quickly so you can receive treatment within a timely fashion.

nutzy: I had undergone a mitral valve replacement in December 2002 with a prosthetic one. I’m taking regularly Coumadin(Warfarin) weekly dose 22,5mg; is not easy to preserve the INR between 3 and 3,5...there are a lot of inconveniences, maybe will be easier to use one of the new anticoagulant drugs but I didn't hear. Even about a trial for people with mechanical valve. I’ll be happy to hear your comments about this issue.

Natalie_Evans,_MD_: Although you have trouble regulating your INR, unfortunately the new anticoagulants are contraindicated in valves. You may wish to address this by enrolling in a Coumadin clinic if you are not already or getting a home monitoring device. Both of these methods of INR monitoring are superior to having your INR managed by a single physician.

Jab3698: I was diagnosed with thrombophilia in 1999 and on Coumadin ever since. I had a DVT and PE at 22 and 39 yrs of age. I am homozygous mthfr, prothrombin, and antithrombin. Are there different blood thinners or other medications available besides Coumadin to help me avoid more episodes as I age. I should also mention, I have high BP, insulin resistance, elevated cholesterol, and panic/anxiety disorder. I am 55 yrs old and relatively active(walker). Also, should I see a hematologist or continue with my cardiologist?

Natalie_Evans,_MD_: There are other anticoagulants, or blood thinners, besides Coumadin (warfarin), including injected low molecular weight heparins like Lovenox and Fragmin, as well as the new oral medication rivaroxaban (Xarelto). Rivaroxaban is fairly new to the market and we aren’t sure whether it works as well as or better than warfarin in patients with thrombophilias like yours. You may wish to see a hematologist or vascular medicine specialist to learn more about anticoagulation options. Our team of vascular medicine specialists at the Clinic has lots of experience caring for patients with conditions similar to yours.

RobertK: I have been on Coumadin for some time and thinking about switching to xaralto or pradaxa. I have a very active lifestyle which would be nice not to have my blood checked - but on the other hand - I am concerned about injury. For Coumadin, I can use an agent such as Quickclot to stop bleeding for injury - but would this work for these other agents.

Natalie_Evans,_MD_: QuikClot, a commercial product that can be placed on an open wound to stop bleeding, probably would be equally effective regardless of whether you’re on Coumadin, Xarelto, or Pradaxa. We don’t know for sure as it has not been studied specifically in patients on anticoagulants.

John_Bartholomew,_MD: Xaralto or Pradaxa cannot be neutralized or reversed where as Coumadin or warfarin can be reversed. You should take that into consideration when making the switch.

Blood Thinners and Pregnancy

Fleur42: Good afternoon. I receive IVIG treatment for low IgG, and am now 6 weeks pregnant (a big surprise at age 43). My IVIG treatment has been delayed until a coagulation panel could be completed, as both the treatment and pregnancy pose a risk for blood clots. I also have Mitochondrial Disease (which means there are several medications I can't take due to mito toxicity) and am allergic to corn / corn derivatives (i.e. such as corn starch, polysorbates, and dextrose/maltose - which are found in many medications).

- If the results show potential issues and I'm prescribed a blood thinner, is there one that would be safer for me?
- Also, are there other risk factors for clotting that I should watch out for / avoid?
- I had planned an overseas plane trip, which will now be around my 5 1/2 month timeframe. Would it be too risky to make that trip?

Natalie_Evans,_MD_: In most cases, for pregnant patients who require blood thinners we use low molecular weight heparin injections like Lovenox and Fragmin. Other medications are either poorly studied in pregnancy or, like warfarin, may be associated with birth defects and other fetal complications. The risk factors for clotting are many, and you may wish to talk to a specialist to pinpoint your specific risk factors. Generally speaking, the strongest risks for blood clots include: orthopedic surgery on the legs, immobilization of the legs with casts or other devices, surgery in general, hospitalization, and cancer. Hormones play a role as well. Presumably you are seeing an obstetrician who specializes in high-risk pregnancies. That person can help you make a decision as to whether plane travel at 5 ½ months is safe.

Varicose Veins and Spider Veins

Andreea: How effective are Sclerotherapy and Microphlebectomy? Do they cause scarring? Are you more likely to develop vein problems if you had these two procedures done? How can larger blue veins around the eyes can be effectively treated?

Natalie_Evans,_MD_: Sclerotherapy and microphlebectomy for varicose veins and spider veins are very effective in carefully chosen patients. In some cases they can cause scarring, but doctors who do these procedures take precautions to minimize scarring. Sometimes the veins can grow back, and in very rare cases there can be problematic blood clots that occur after these procedures. I do not recommend treatment of blue veins around the eyes because of the risk for scarring or hyperpigmentation, or dark coloration, of the skin, but a plastic surgeon or dermatologist might be able to give you better guidance on treating cosmetically unappealing veins on the face.

Atrial Fibrillation

newburyst: Currently I am on baby aspirin , after 2 ablations 2009 and 2011. Last week I had 2 bouts with afib one for 12 hours and one for eight. This is the first time in a year I had anything...should I be on Coumadin.

John_Bartholomew,_MD: I suggest that you follow up with your electrophysiologist to answer this question.

maidenrock: Will taking an anticoagulant to prevent stroke from atrial fibrillation also reduce blood pressure?

Natalie_Evans,_MD_: No.

Terra: Hi - I have lone atrial fibrillation for the last 6 years and episodes are becoming more frequent. I understand that most blood clots that occur with atrial fib are formed in the left atrial appendage due to decreased blood flow. My questions are 1.) When a person is in afib, how fast will a clot form? 2.) What other factors will contribute to a clot forming (dehydration?) while a person is in afib? 3.) Is the clot risk eliminated immediately when sinus rhythm is restored? In other words, after converting to NSR, if no stroke occurs, can a person assume none will occur from that episode? 4.) While in afib do clots always form if no anticoagulants are being taken? Thank you for your help.

Natalie_Evans,_MD_: No one knows how fast a clot will form. Certainly factors that make blood flow sluggish contributes to clot formation. The clot does not dissolve immediately when NSR is restored so there does continue to be stroke risk even in sinus rhythm. No - clots do not always form in atrial fibrillation - but the risk is high enough in many patients to warrant taking anticoagulants.

liesel: 2/2004 I received a stent due to 90% blockage in the LDL. 10 hrs. later I had a major heart attack. They performed an emergency angioplasty thru the same groin area and inserted another stent. Two days after being released from the hospital I developed blood clots in my right leg due to the trauma in my groin area. I was on Coumadin for about 8 months until the clots disappeared. I had a really hard time with Coumadin, constant nose bleeds, etc. As soon as my clot was gone, my PCP agreed to discontinue the Coumadin since he knew how much problem I had with it.

In October of 2006 I was diagnosed with Factor V Leiden homozygote. Up to this point I have resisted taking a blood thinner for life. I am doing all the right things, like eating right, exercising, taking 81 mg Aspirin, Plavix, and Fish Oil. I have had 8 A-Fib episodes in the last 2 ½ years. It always happens during rest. Pulse raced from a resting heart rate of 50 to between 120-180; takes from 2 -6 hrs. to revert to sinus rhythm.

During these A-Fib episodes I chew 1 whole Aspirin, take 1-2 Xanax, 1 Metoprolol ( the faster acting tartrate). My question: due to the fact that these A-Fib episodes happen so seldom, how comfortable should I feel not taking a blood thinner.

Natalie_Evans,_MD_: Patients who go in and out of atrial fib may be at increased risk for stroke depending on age and other factors. In many cases, it is ideal to have atrial fib patients on blood thinners even though the episodes are infrequent. You may wish to talk to an electrophysiologist to better determine your risk of stroke off of blood thinners.

John_Bartholomew,_MD: Also - if your bleeding was always in the nose, I would suggest you seen an ear nose throat specialist to prevent that issue from returning if you needed blood thinners.

zendor26: I had 3 mini-strokes. I have been diagnosed with atrial fibrillation (AF) which has deemed to be the cause and I now take Pradaxa. (1) is there something I can change in my life to eliminate the AF (if I could find out what) or is it the result of an aging heart? and (2) if I eliminated the AF, could I stop taking Pradaxa? thank you! richard p.

Natalie_Evans,_MD_: The irregular heart rhythm atrial fibrillation certainly is more common as we age. There aren’t many lifestyle changes you can make to reverse atrial fibrillation, but there are a number of treatments to put you back into a normal heart rhythm if you are symptomatic, including medications, electrical shocks to the heart, and catheterization procedures that aim to disrupt the abnormal signals your heart sends out. However, we know that many patients with a history of atrial fibrillation can go in and out of the irregular rhythm despite feeling fine, and so often times they must remain on anticoagulants like warfarin and Pradaxa (dabigatran). You may want to talk to an electrophysiologist, a cardiologist specializing in heart rhythm, to discuss treatment options.

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Reviewed: 05/13

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