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Julia Kizhner
Julia Kizhner, Physician Assistant
Category: Health
Satisfied Customers: 1126
Experience:  7 years experience working in Primary Care as well as Gastroenterology, Sleep Medicine & Weight Loss
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TWO QUESTIONS, SO PLEASE HANG ON 91 yr old mom has AT. First

Resolved Question:

TWO QUESTIONS, SO PLEASE HANG ON:
91 yr old mom has AT. First developed several years ago and cardioversion was planned. Started on warfarin, but blood numbers never were right, then heart got back in rhythm.

AT returned. Dr. suggested that cardioversion risk and fact of only 50% chance of its working and no guarantee of the heart staying in rhythm afterward made it reasonable not to have the procedure.

Mom takes amiodarone and aspirin. If congestive heart disease symptoms occur (she has none most of the time), she takes a diuretic. She strongly resists adding warfarin again (using aspirin instead) because of the need for weekly trips to have blood checked.

QUESTION ONE: since the treatment with warfarin would not be to prepare for cardioversion but just to lesson stroke risk, HOW OFTEN WOULD SHE NEED HER BLOOD CHECKED IF ON WARFARIN?

In the last week, she has had 3 episodes of extreme dizziness and even a feeling of being displaced from her body with the first one. She went to the dr today who had her take a MRI. Diagnosis: Small Vessel Disease. She has neither high BP nor diabetes, but does have narrowed carotids and familial high cholesteral. WE ALL EXPECTED A DIAGNOSIS OF TIA, AND HOPED SHE WOULD TAKE WARFARIN AGAIN. But I have seen no connection between taking a "blood thinner" and reduction of the stroke risk suggested by small vessel disease (and she already has the strongly associated AT with stroke and will not take a thinner), so

QUESTION TWO: Would taking warfarin decrease the progression or attacks associated with small vessel disease?

THANKS for help.
Submitted: 4 years ago.
Category: Health
Expert:  Julia Kizhner replied 4 years ago.

Hello and thank you for your question.

 

You are asking very interesting questions which I would like to help you answer. I would also like to explain to you why it is important for your mom to take Warfarin.

 

I would first like to ask you a couple of questions. Is your mom at high risk for falls? Is her gait stable? Does she have history of falls? Also, I didn't understand if your mom already has a history of a stroke or TIA?

 

Looking forward to hearing back from you,

Julia

Customer: replied 4 years ago.

Dr. Kizhner,

 

Mom's gait is stable, no history of falls, no history of stroke or TIA. Went sky-diving (buddy system) for 83rd birthday. Still lives alone, does own cooking.

Expert:  Julia Kizhner replied 4 years ago.

Thank you for your reply.

 

I will give you a rather long answer, so please feel free to follow-up with any questions you might have.

 

I would like to explain why it is important for people who have atrial fibrillation to take Warfarin. There are 4 chambers in the heart - 2 ventricles and 2 atria. In atrial fibrillation, the left atrium, instead of having normal beats, it begins to fibrillate. Blood starts to stagnate at the bottom of the chamber. Once the blood stagnates, it forms clots. Once in a while, the left atrium can come out of the atrial fibrillation mode and give a normal contraction. At that point, a blood clot which has been sitting on the bottom of the chamber can get released, travel to the brain and cause a stroke.

 

We use Warfarin to make sure that the blood sitting in the bottom of the chamber does not stagnate and does not form a clot. 7-10% of people with atrial fibrillation have strokes and unfortunately, most of the atrial fibrillation strokes bring quite devastating results.

 

When someone begins taking Warfarin, initially their blood work will need to be done once a week, however, once the desired option is achieved, blood draws will need to be done once every 3-4 weeks. One of the options that your mom can consider is having her doctor refer her for home care nursing. In that instance, a nurse comes to her house to draw her blood instead of having her to drive to the doctor.

 

There is a score which is called CHAD2 score. It measures a risk of someone having a stroke based on their age and medical conditions. Here is a link to the site where you can check out more about CHAD score:
http://www.cardiology.org/tools/risk_of_stroke_AF.html

Your mom's score is 2 (her age and history of heart failure). This means her annual risk for having a stroke is 4%.

 

Now, about small vessel disease...small vessel disease is completely expected for someone her age. All that means is that there is some narrowing of small blood vessels in the brain. This is associated with age and with cholesterol. Yes, it does put people for a risk of a stroke. Anyone over the age of 60 or 65 has some kind of small vessel disease, however, that is not what is putting your mom at risk for a stroke. She has a much higher chance of having a stroke secondary to atrial fibrillation rather then small vessel disease. Warfarin will not prevent a stroke from the small vessel disease, it will only prevent stroke from Atrial Fibrillation. Aspirin, however, we use to prevent strokes associated with small vessel disease. Also, small vessel disease does not cause any symptoms unless your mom is actually having TIAs or strokes (which, based on MRI, I understand she did not have).

 

If your mom is not at risk for falls, it would probably be wise for her to be on Warfarin to prevent a devastating effects of a stroke.

 

I know this is a lot of information. Sorry for such lengthy answer. I hope you find this information helpful. Please feel free to follow-up with any questions or let me know if you need any clarifications on anything I said.

 

If I have answered your questions, please click the green "Accept" button. Otherwise your deposit stays with JustAnswer and I do not get credit for my work.

 

Best wishes,

Julia

Julia Kizhner, Physician Assistant
Category: Health
Satisfied Customers: 1126
Experience: 7 years experience working in Primary Care as well as Gastroenterology, Sleep Medicine & Weight Loss
Julia Kizhner and 5 other Health Specialists are ready to help you
Customer: replied 4 years ago.

Thanks, XXXXX XXXXX've sent your answer on to my brother, who will also find it helpful.

 

I'm going to suggest again to Mom to take warfarin.

 

But if she takes warfarin, she'll need to stop aspirin, right?, and if aspirin helps with SVD as you said, well, looks like a trade off.

 

You do not have to reply to this, just my musing.

 

Best,

Tom Nunnally

XXXXX@XXXXXX.XXX

Expert:  Julia Kizhner replied 4 years ago.

Thank you for accepting my answer.

 

I do want to say that actually, I lot of people who take Warfarin are also on Aspirin 81 mg (baby Aspirin). Granted, it does make them bruise more and they dont like the appearance of the bruises (mostly on forearms/hands), however, it does provide additional benefit.

 

In your mom's case, she has more risk of stroke from atrial fibrillation then from SVD so Warfarin may be more beneficial but, again, she can continue taking Aspirin.

 

When someone is on Warfarin, it is important to stay consistent on medication use and on consumption of greens (salads) because greens have Vitamin K which has a big effect on Warfarin. Too much greens will make Warfarin too active. As long as the dose of greens that your mom consumes daily stays consant, dose of Warfarin can be easily adjusted. She will be learning all this once Warfarin is started.

 

Good luck and feel free to follow-up anytime in the future.

 

Julia

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