Using the pacemaker as diagnostic tool

I need to take both medications: anticoagulant (have Paroxysmal Atrial Fibrillation) and antiplatelet (advanced CAD with 6 cardiac stents)

However, because of the high bleeding risk, this is not allowed to take both for long time.

I also have a pacemaker Medtronic Azure S with Bluetooth capability.

My question is:

Anybody having experience for using the pacemaker as diagnostic tool that allows the anticoagulant Eliquis to be taken as pill in the pocket? (only when Atrial Fibrillation is in place)



by Gemita - 2022-04-23 14:53:39

Ratcheva, my husband has stents and at one time he was taking triple therapy, Aspirin, Clopidogrel and Apixaban.  Clopidogrel was dropped after three months and Aspirin after one year, leaving only Apixaban for AF stroke protection.  Because of my husband’s age (83) and reduced kidney function, he was switched to low dose once daily 30 mg Edoxaban, since 2 x 5 mg Apixaban (usual dose for AF stroke protection) was not tolerated and caused urinary bleeding.  He has had no trouble with bleeding on Edoxaban and is fully protected against an AF related stroke.

Anticoagulation is not used as a Pill in the Pocket (if only), since you may not always be aware that you are in AF and it would only take a brief episode of AF to put you in danger of a stroke.  The pacemaker cannot be used as a diagnostic tool since you would have to be monitoring round the clock to look for short runs of AF and your clinic would not be able to provide such a service.  Also Apixaban needs to be taken regularly at the same time of day to provide you with 24 hour cover.  If you miss one dose or take it on an as needed basis, you may not have sufficient medication in your blood stream when AF is present, so all in all Pill in the Pocket not a good idea.  

I wonder if you are a candidate for a Watchman device if you need to stay on dual therapy Aspirin/Apixaban?   What do your doctors suggest?  My husband’s cardiologist was happy for us to stop Aspirin one year after his three stents.  Are you saying that you need to remain on both?  My husband has extensive heart disease too and has had strokes.  


by ratcheva - 2022-04-24 05:06:00

Thanks for your detailed explanations, Gemita! 

My doctors are not recommending catether ablation for my AF, or Watchman device.  They prescribed Eliquis 2 X 5 mg and Bisoprolol 2.5 mg. However, it seems to me that I need also an antiplatelet med for long term use since my CAD is so serious. 

3 months ago, I got the PM with no AF episode registered. So according to the doctors I have to take Eliquis to avoid AF related stroke and not to take antiplatelet med for my extensive CAD.

Strange, but I understand that there is no easy solution to my problem, so I will stay with the doctor's recommendations.

A dilemma I well know

by Gemita - 2022-04-24 09:09:10

Ratcheva, you are right to be guided by your cardiologist and other health professionals who will know you best.  It is a worry I know to try to find the right balance to help with all our health conditions.  

I was told Aspirin alone is not adequate to protect from an AF related stroke and indeed could cause more harm than good with regards to bleeding risk, especially in the elderly.  A recommended dose of Apixaban (2 x 5 mg daily) is effective to protect against a stroke while generally being kind on our digestive system.  This dose may need to be reviewed in the elderly depending on other health conditions, and reduced in certain cases.  

I tried to avoid taking an anticoagulant (now on low dose Edoxaban too because of my low body weight) for AF stroke protection.  Prior to my pacemaker I had extensive discussions with my anticoagulation clinic doctors about taking baby Aspirin instead but I was firmly told it wouldn’t protect me.  They were very kind, patient and completely understanding though of my fear of being on lifelong anticoagulants. 

Don’t be afraid to discuss any side effects with your clinic.  There are several different anticoagulants which can be tried if one doesn’t suit, but Apixaban is one of the safest out there I believe.  

AF may start (or stop) at any time, for any reason following a trauma, like for instance a pacemaker implant.  My arrhythmias certainly got worse initially.  If you are uncertain of the advice given, I would speak to your doctors again for reassurance.   I would particularly focus on whether Aspirin can be safely stopped with six stents and your CAD as that seems to be your concern at the moment.  As I mentioned, my husband (with three stents and CAD) was told to stop Aspirin after 12 months following his drug-eluting stents which were placed in 2017. I know guidance about stopping Aspirin is dependent on the patient's condition and the type/age of stent.  I believe there is still debate among cardiologists about the optimal duration beyond 12 months of Aspirin therapy.  One cardiology team felt my husband should continue low dose Aspirin indefinitely, together with an anticoagulant for his AF, but another cardiologist recommended stopping Aspirin, so a complex picture.  

A dilemma I well know

by ratcheva - 2022-04-24 12:17:56

Thanks for your detailed comments, Gemita!

I think we have a common understanding of the problem, that does not have a good solution for the moment.



by TAC - 2022-04-29 12:29:06

Gemita comment is correct. Eliquis can't be used as a "use if needed pill". It must maintain an appropriate blood level to be effective. AF can be undetected by the patient and it can occur at night while sleeping. "Take as needed pill" is not possible. Incidentally, we tend to foccus only about the anticoagulant effect of drugs that protect us from having a stroke. However, the is a lurking threat that we tend to overlook. It's the danger of a  very dangerous, life-threatening hemorrhagic event. A brain hemorrage or hemorragic stroke which is deadly. Also a dangerous gastrointestinal bleeding, like one I suffered recently from Eliquis 5mg. There are no easy solutions once we pass a certain age treshold.

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