#325 Blood Thinners versus Watchman for Atrial Fibrillation: Which is Best?
Dr. John DayDr. Day is a cardiologist specializing in heart rhythm abnormalities at St. Mark’s Hospital in Salt Lake City, Utah. He graduated from Johns Hopkins Medical School and completed his residency and fellowships in cardiology and cardiac electrophysiology at Stanford University. He is the former president of the Heart Rhythm Society and the Utah chapter of the American College of Cardiology. |
Blood Thinners versus Watchman for Atrial Fibrillation: Which is Best?
No one wants an stroke and most of my AFib patients at higher risk for stroke don’t want to take a blood thinner for life. Fortunately, AFib patients at low-risk for stroke don’t require blood thinners. But for those who have to take a blood thinner, are there any alternatives? In this article we’ll discuss AFib strokes, the role of the left atrial appendage, and whether blood thinners or Watchman is best for AFib.
What Causes Atrial Fibrillation Strokes?
Strokes are common in AFib patients because the complete electrical chaos in the atria leads to loss of pumping. The result is stagnant blood flow, and stagnant blood clots easily, especially in the left atrial appendage. The left atrial appendage is a dead end pouch in the left atrium where clots form when atrial fibrillation causes the upper chambers not to pump.
When these clots break off from the left atrial appendage and enter the bloodstream, they are like missiles that can go anywhere in the body and do incredible damage. Clots that go to your gut, kidneys, or leg can all leave a trail of destruction. But when clots go to the brain, resulting in a stroke, the effect is immediate, devastating, and often deadly.
What Happens During a Stroke?
During a stroke, the brain is starved of oxygen and nutrients, a situation that almost immediately begins to kill brain cells. You’ll also recall from previous posts that AFib is usually associated with high blood pressure. That’s a double disaster, since years of high blood pressure can damage the arteries in the brain long before the atrial fibrillation clot ever arrives. For all of these reasons, atrial fibrillation has been associated with a five-fold increase in the risk of stroke.
Those risks aren’t uniform, of course. They increase with age, and also with other complicating medical conditions. But even among AFib patients who are young and relatively healthy in other ways, no one with AFib is safe from stroke. Strokes in patients with atrial fibrillation that do not kill often result in greater disability compared to strokes caused from other reasons. Even “small” strokes over time can impair cognition and greatly increase the risk of dementia.
Why Are Blood Thinners Used for Atrial Fibrillation?
Because atrial fibrillation increases stroke risk, doctors are often keen to prescribe an anticoagulant. These medications, also called blood thinners, help prevent clots from forming inside your heart. And the less likely you are to form a blood clot in your left atrial appendage, which can happen when the upper chambers of the heart stop beating during AFib, the less likely it is that a clot will break off, cutting of the blood supply—and thus the oxygen—to the brain or other organs or structures.
Left Atrial Appendage Closure (Watchman or Amulet devices)
One way to get off blood thinners is having your left atrial appendage closed or removed. The two most popular non-surgical ways to close off the left atrial appendage are with the Watchman device from Boston Scientific or the Amulet device from Abbott Laboratories. Implanting either of these devices in the heart is a relatively simple outpatient procedure through an IV in a leg vein.
Intuitively, it seems this should be an enormously effective solution. After all, approximately 90 percent of all AFib strokes arise from blood clots forming in the left atrial appendage, a small sac in the muscle wall of the left atrium. Many doctors believe closing off this part of the heart, through the insertion of a closure device that plugs the sac’s opening, can keep clots from coming loose and heading toward the brain, where they can get stuck and cause a stroke.
4 Challenges with Left Atrial Appendage Closure (Watchman or Amulet)
But what seems intuitive and what happens in real life can, in some patients, be two different things. Studies show that a left atrial appendage closure device, along with a daily aspirin, offers a survival rate equivalent to blood thinners. However, with these left atrial appendage closure devices, like the Watchman or Amulet, there are some important things to consider.
1. You have a 1 in 50 of developing a blood clot on the device
This is intuitive, too, because any time you stick a foreign object into the circulatory system, the body wants to form a clot, so you may be trading one potential cause of stroke for another. And if you are that 1 in 50 then you may never get off blood thinners.
2. Your cardiologist may increase your stroke risk with a left atrial appendage leak
There is also a small chance that your cardiologist will leave you with a left atrial appendage leak after implanting the Watchman or Amulet devices which means blood can still get in and out of your appendage. This is not a good thing—a leak can dramatically increase your stroke risk even higher than it is right now.
3. Left atrial appendage closure does nothing for AFib
Closing off the left atrial appendage does nothing for your AFib. While it offers stroke protection, you will still have AFib and you will still be at an increased risk of premature death, dementia, and heart failure.
This is an important consideration as our studies have shown that with a successful ablation procedure your long-term stroke risk, as well as your risk of death or dementia, is no different than someone who has never had atrial fibrillation. In other words, based on our experience, a successful ablation could eliminate not only your AFib but all of the other increased risks with AFib as well.
4. Aspirin may be just as risky as a blood thinner
After you get through the healing process of left atrial appendage closure, your cardiologist will still keep you on aspirin daily. While aspirin may seem much safer than a “blood thinner,” studies show that there is no statistical difference in the bleeding risk of aspirin versus the safest blood thinner, Eliquis (apixaban).
Despite the Risks Patients Love the Watchman Procedure
Despite the 4 significant challenges with left atrial appendage closure with either the Watchman or Amulet devices, patients still love this procedure. Blood thinners frighten patients and many of my patients will do anything to get off these medications. And because left atrial appendage closure can be thought of as a blood thinner alternative, patients love them.
Also, if you liked the photo attached to this article, it was one of my mountain running trails until the deep snow came a month ago.
Disclaimer Policy: This website is intended to give general information and does not provide medical advice. This website does not create a doctor-patient relationship between you and Dr. John Day. If you have a medical problem, immediately contact your healthcare provider. Information on this website is not intended to diagnose or treat any condition. Dr. John Day is not responsible for any losses, damages or claims that may result from your medical decisions.
Dr. Day,
You performed a cardiac ablation on me. It went well from all could tell. The only difference I noticed is that my ear feels stopped in my testing heart rate increased from 42 to 51. I’m quite active, physically and scored zero on all six tests for heart attack or stroke risk. Nevertheless, a little over a year ago, I got a clot in my left calf. I was on Eliquis for 3 months then came off. I got COVID after that, with very minor symptoms for 3-4 days. Several months later, while mountain biking and working out every day, a had a little pain in my calf and had a ultra sound and a CT Scan. All clear. But 3-4 months later, I developed a clot in my other calf and now I’m back on Eliquis, perhaps indefinitely, a prospect I despise. I would love to find a better option.
Dr Day did two ablations on me 2014 and 2017, being in normal rhythm was great but 2021 I was in permanent AFib. I decided not to have a third ablation, didn’t check to see if it was an option. In 2021 I had the watchman procedure with the new model. I didn’t have any serious side effects from Eliquis, usual bruising and slow healing cuts. My lifestyle was risky on it and I was unwilling to give that up. It came down to cost of medication and lifestyle choices. I already take a baby aspirin for other risk factors so a non factor for me. Of course I wish I stayed in normal rhythm, time will tell if I chose wisely.
To Dr. Day,
I have been trying to decide as to whether I should proceed with the Watchman since I had an Ablation in March of last year. Since then I have tried to research my questions. Due to the fact that Covid has not let up. I’m still very nervous about going into the hospital for anything but I believe at this point I would get the Watchman if I could get answers to these questions.
1. We have been trying to get good information on the cost of this procedure, the out of pocket or what will Medicare cover. In other words our out of pocket. We have still not received information about that. When we talked to Medicare they said the medical codes for the procedure did NOT show up in their system.
2. After all of the research and attending St. Mark’s online meetings, I feel ready to have it done. I do still need to find out about the out of pocket costs. I also would like to find out when and if there are any good times that will be safe from Covid.
If you can find out a contact person that is actually going to get us help to move forward we would greatly appreciate it. At this point we would have the info we need to move forwards. Thank you for all the help that you and Dr. Behunin and others at the hospital have shared with us. Thank you so much for the Ablation. It is so helpful and I feel so good. I just don’t want to do anything that brings back A-Fib again.
Have a Great New Year Dr. Day You have done 2 afib operations on me one in 2012 and one in 2013. i have no symptoms of afib thanks to you I take my zeralto daily with no complications I think I will stick to that if it’s not broken dot fix it. Have a great year.
Susanne Tewes