Thrown A Curve Ball - CHAD-2

[corrineinwa]

Peter is 6 weeks post-op tomorrow and all agree that he's doing very well.

We seem to have found a therapeutic level with his Coumadin (INR of 2.37 today so dose remains the same).

But today came the blow that he has a CHAD score >2 so our hopes of him coming off the Coumadin at 3 months might just be a pipe-dream.

Although he has a history of intermittent A.Fib pre-surgery, and it was continual during the days immediately post-op (cardioversion was unsuccessful), 2 seperate EKG's over the past 4 weeks showed normal sinus rhythm but maybe it's too early to be sure it's a permanent thing.

But even without that, a history of a stroke gives him 2 points and he's not far short of being 75 so gets a bit extra for that and the recommendation is to continue the anticoagulation. No hypertension or diabetes thankfully.

I was given to believe that Peter would be on Coumadin (and Amiodarone) just for 3 months post-op (unless the A-Fib became an issue again). I'm a little down about this - until today, no one had mentioned CHAD.

One thing I forgot to ask was whether it's the norm to continue with the Amiodarone too. I confess, it's that stuff that gives me the bigger concern.

Anyway. I feel better for just venting a bit. Peter doesn't seem to (or doesn't want to) understand one shred of any of this stuff and I don't have anyone else I'd care to share it with.

I guess this is just part and parcel of this roller-coaster ride and tomorrow is another day so I'll just put my big girl panties on and just get over it.

Thanks for listening.

 

[Ross]

Doctors drive me nuts with their zeal to use Amiodarone. It was never intended to be used as the first treatment, but as a last resort. There are other things they can try. The big thing is to get him off of it, if at all possible. It is nasty, dangerous stuff.

 

[ALCapshaw2]

Corrine -

You are right, long term use of Amiodarone is the Main Concern. Even the manufacturer states that it is the antiarhythmic of Last Resort. When you feel brave, you may want to read the Information Sheet that comes with the package (ask your pharmacist for a copy), or do a Search on VR.com for LOTS of discussion on this drug, or Google "Amiodarone". Even the FDA has a warning about long term or high dose side effects.

Doctors like to use Amiodarone because it is also the Sledge Hammer of antirhythmics. It works Fast, and they can send their patients home on schedule. In other words, Amiodarone is for THEIR Benefit, not necessarily the patients. For Short Term Use, it seems to work out OK.

It's probably time to start talking with Peter's Cardiologist about finding an alternative. SOTALOL (generic form of BetaPace) works well at controlling A-Fib for MANY of our members and has WAY FEWER side effects. You may want to ask his cardio about switching over.

Sotalol carries a 'cautionary note' that it should be started "in hospital" for a few days, "just in case" it triggers another (possibly more dangerous) arrhythmia. Some of our members were started on it without hospitalization. I don't have a good feel for that risk.

Once the body becomes used to Sotalol, the risk of causing other types of arrhythmias seems to go away. That's a good question for his Cardio and Pharmacist. Then the major side effect is some (mild) dizzyness which also seems to dissipate after a few weeks.

If you haven't read the "Sticky's" at the top of the Thread List in the AntiCoagulation Forum, this would be a good time to start doing so. With PROPER management, Coumadin / Warfarin is well tolerated by almost all patients.

Nancy's husband Joe was on it for decades, also into his 70's. To be complete, the Bleeding Risk does rise somewhat with age, but again, with proper management the risks can be balanced. We have some other members who have been on Coumadin / Warfarin for decades (e.g. GeeBee, RCB, others whose screen names escape me at the moment).

Hang in there. I have every confidence that You can handle it. It would be nice if Peter took a little more interest in understanding his issues and treatments.

OTOH, it is good that he is 'puttering'. Take it from another 'country living putterer', puttering in the outdoors provides a "Connection with Life and the Universe" it is "doing God's work". Puttering will inspire him to want to continue living a useful and satisfying life. That is a GOOD SIGN that I'm sure his Doctors are pleased to see!

As Nancy says in her signature line,
"Never Give In and Never Give Up"

'AL Capshaw'

 

[Nancy]

Yup, Joe was on Coumadin for many, many years. It was just another pill or two for him, and just a few more tests. He never stressed about it, and went on with his life as normal.

I am sure when you are expecting one thing, and another thing happens, there is an adjustment to make, but you will make the adjustment, especially because it will keep him safe.

Joe also had chronic afib for many, many years, and couldn't take the regular meds that are given for it, so his doctors just let it go. It did make him a lot more tired because the heart was not efficient. It would have been much better if he could have taken something to keep it in normal rhythm. There were times when the afib would convert on its own, but eventually it went back into afib or aflutter.

He had to be on Coumadin anyway because he had two mechanicals, so he already had that protection.

Life goes on and Peter will be OK.

 

[deek]

I don't know anything about this but I can relate to the ride, up and down, it seems. Hang on and take it one day at a time....that's all we can ever really do. Sending you and Peter positive vibes.
Dee

 

[MissMelis]

I'm with Dee. Don't know much about it but throwing support and encouragement behind you 100%.

Melissa

 

[tobagotwo]

I agree on losing the Amiodorone. This is a drug that can perform miracles in the short term, but may exact a very dear payment if continued for a long time. It even takes months for it to leach out of your system after you stop. Be sure not to stop until a doctor works out a plan for easing him off it. That can be hazardous as well.

The CHAD score is independent of his valve. The fact that he is taking three months of Coumadin now for his valve has absolutley no bearing on whether he should take it for other reasons. That's just convenient timing for the doctor to sell the notion of continuing to take it. Based on the CHAD chart, the doctor has known all along that he was going to try to keep Peter on Coumadin: any patient who has had a previous stroke fits CHAD guidelines for warfarin ACT.

Peter is 75, which means he is a grownup. He has a right to determine the risk he wishes to bear for himself, if he is sufficiently bothered by the warfarin. It's not a state law that he participate in ACT. There is also aspirin or clopidegrel, which may be less effective, but may also reduce the stroke risk somewhat nonetheless. Warfarin, and to a lesser extent aspirin and Plavix, can have risks of their own, especially if he has any history of stomach/intestinal bleeds or intracranial bleeds. This is a decision he needs to make in conjunction with his doctors and family, not a foregone conclusion.

Please note in the charts below that the CHAD recommendations start with daily aspirin for people with no risk factors, so it may lean a bit toward the medicating side.

For others, here is information about CHAD, taken from http://cme.medscape.com/viewarticle/543645_2 (Hugh Calkins, MD), with some minor changes in formatting to work on the VR.com pages:

The new guidelines also provide the full CHAD (Cardiac Failure, Hypertension, Age, Diabetes, and Stroke) scoring system, and they clearly specify when risk factors indicate that aspirin is sufficient and when risk factors suggest a patient is a candidate for warfarin. As shown in Table 2 , aspirin is sufficient in an AF patient with no other risk factors for stroke. If there is 1 moderate risk factor, either aspirin or warfarin can be used, according to patient preference. Warfarin is clearly indicated if a patient has 1 high risk factor or ≥ 1 moderate risk factor.

Table 1. ACC/AHA/ESC 2006 Guidelines: Risk Factors for Stroke
Less Validated/Weaker Risk Factors--- Moderate Risk Factors----- High Risk Factors
Female gender--------------------------- Age ≥ 75 yrs --------------- Previous stroke, TIA, or embolism
Age 65-74 yrs--------------------------- Hypertension --------------- Mitral stenosis
Coronary artery disease------------------ Heart failure ---------------- Prosthetic heart valve
Thyrotoxicosis--------------------------- LVEF ≤ 35% ---------------- Diabetes mellitus

LVEF = left ventricular ejection fraction; TIA = transient ischemic attack


Table 2. ACC/AHA/ESC 2006 Guidelines: Recommended Therapies According to Stroke Risk
Risk Category ------------------------------------- Recommended Therapy
No risk factors ------------------------------------- Aspirin, 81-325 mg daily
One moderate risk factor---------------------------- Aspirin, 81-325 mg daily, or warfarin (INR 2.0-3.0, target 2.5)
Any high risk factor or > 1 moderate risk factor------- Warfarin (INR 2.0-3.0, target 2.5)*

*If mechanical valve, target INR greater than 2.5

Best wishes,

 

[corrineinwa]

I'm sorry that I didn't make myself clear - it was a long day yesterday and I should know better than to type when I'm tired.

Peter is doing just well on the Coumadin and if he has to continue with it, then fine. The Amiodarone is the one that causes me concern.

What bothered me was that up until yesterday it was my understanding that provided Peter's heart proves to be in normal sinus rhythm then the Coumadin and Amiodarone were just going to be a 3 month thing.

I now find out that because of his history of a stroke and age etc., he has the CHAD score of >2 and continued Coumadin is recommended. What I haven't been able to find out about is whether Amiodarone is also to be continued. It's not the Coumadin.

Al and BobH.

Totally agree with you!

It would be nice if Peter were more involved in his treatment and care. He is grown-up and in an ideal world, he would make the decisions for himself.

Unfortunately, this is not an ideal world.

I'm not involved in this because I particularly want to be - I just don't have a choice.

 

[ALCapshaw2]

Corrine -

Concentration and Short Term Memory can be 'compromised' after OHS, making it difficult to learn and retain "New" information.

This 'may be' an issue along with other pre-existing issues. It's probably best to continue as you are until he is more fully recovered (and it could be a year or more before he feels he has reached his 'full surgical benefit', both physically and mentally.)

You have been an OUTSTANDING Supportive Spouse.
I suspect and hope Peter recognizes and appreciates this.
From your description, it appears that he does depend on you to care for him and keep him going on the right track. Bless You for your efforts!

'AL Capshaw'

 

[Nancy]

I agree with what Al has said about cognitive problems which happen after surgery in the early stages of recovery. It makes it hard to do a lot of comprehending and in depth learning.

I was 10 years younger than Joe and healthier, and I had an interest in medical stuff and computers.

Joe had no interest in computers and just went along with what his doctors said unless there were issues he didn't feel were being addressed.

But I did all the research online and learned so much. And this site was an extremely valuable resource. Along the way as I learned, I was better able to communicate with his doctors, and I started learning from them as well, many, many technical things.

So, like peeling an onion, you learn these things one layer at a time. Before you know it, you will have a head full of knowlege.

If this is not Peter's "thing", continue doing what you are doing. It will all come in handy in the future for Peter, and believe it or not, for yourself too, because you will learn many non-heart things and how to deal with medical people and institutions.

That's very important. Being your husband's advocate is a blessed job.

 

[corrineinwa]

Peter had pre-existing issues anyway and I don't think his heart surgery has made them any the worse although it's certainly made things more difficult.

I'm lucky to have him here so I'll continue to do what has to be done to make sure that doesn't change.