Doper Docs - current recs for Warfarin use for A-fib?

You our not our doctor, this is not real doctor advice, I promise not to sue you, etc. We’re getting conflicting doctor recommendations, so I thought I’d pump your brains for medical opinions.

My SO is a 57yo male. Chronic atrial fibrillation diagnosed Sept 2000. One month later he had an MI with complete blockage of the RCA. A stent was placed and he was put on a holy host of antihypertensives, digoxin and warfarin.

Other health history includes hyperlipidemia, COPD, sleep apnea and diverticulitis (2009) which ruptured, requiring colostomy. In January of this year, he had some left shoulder pain, and the ER docs/cardiologists at the hospital did a chemical stress test (WNL) and ECG (WNL). Dig level was at 0.5 and INR 2.3. They added a daily full strength aspirin to his regimen.

Yesterday, the urgent care doc at the VA (the situation wasn’t urgent other than we needed meds refilled and the VA would do it immediately and free) told us he wanted to take the patient off warfarin, saying that it’s only indicated for a-fib if the patient also has a CHAD score of 2+. His is 1 (MI). So the doc dc’ed the warfarin.

The pharmacist filling the order at the VA seemed awfully concerned about stopping the warfarin, as am I. I was taught that warfarin is indicated for chronic a-fib, period, to prevent the formation of clots behind the valves in the heart which could break lose and cause Bad Things To Happen. But I’m only a nursing student, so what do I know?

We go back in another 3 weeks to have a real intake done with a doc who’s not Urgent Care focused. He has enough warfarin to keep taking it until then, but we’re not sure what to do. I don’t expect y’all to make our decision for us, of course, but I’m wondering what the current recommendations for warfarin use with a chronic a-fib are, and if the CHAD score is really relevant.

(usual non-medical advice disclaimers)

You’re talking about the CHADS2 score, which is one point each for congestive heart failure, hypertension (even if it’s treated), age over 75, diabetes, and two points for history of stroke or TIA. A more recent version (the CHA2DS2-VASc) gives an additional point for being over 65 (so you get two if you’re over 75) and one each for being female or having a history of MI or PAD.

For both scores the general rule is that if you have two points or more you should probably be on warfarin, if it’s zero you probably shouldn’t, and if it’s one you can go either way. (Obviously the newer score puts a lot more people on warfarin.)

BUT, and this is a big but, the guidelines are just that. This is a very individualized decision. The stroke risk might be the biggest variable, but you also have to consider the risk of a bleeding complication from the warfarin, the patient’s compliance (will he really come in to get that INR checked like he should? Will he take the medicine every day?), and the patient’s attitudes (what scares him more–a stroke or a bleed?) and all sorts of other variables.

So the most important thing is that this is a decision made with a doctor who is willing to get to know the patient a little bit. It’s usually not all that complicated, but you can’t just add up a score and be done with it.

Wish I could be more helpful.

Thank you, that is helpful. At least the “could go either way” part.

He is very medication compliant, but has been less INR compliant d/t lack of funds over the last 18 months. Now that he’s hooked up with the VA, that’s not such a problem.

So thank you again. I will let him know what you say and he’ll add it to the pile of information as he makes his decision. :slight_smile:

I take warfarin for A-fib. I was 68 when it was diagnosed and had both diabetes and high blood pressure, both well under control, so I would apparently be given it even under the older guidelines. My wife’s hairdresser had an uncle who after years taking it, decided it was too much trouble (you need a clotting test every six weeks and is a PITA). He stopped and nine months later, he had a stroke and died.