Eliquis and prosthetic heart valves

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erricojj

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To the Eliquis takers out there, please share what you know, if you can...

I came across a web site posted by BMS indicating that "ELIQUIS is not for patients who have artificial heart valves"

This is listed with a red "X" next to it about half-way down this page...

I also found this same warning on page 2 of a Medication guide (attached) that I received with my last refill. "ELIQUIS is not for patients with artificial heart valves."

I've posted this question to my cardiologist and am awaiting a response (which I will share if anyone is interested).

Thanks
 

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Warrick

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Definitely interested to hear what your cardiologist says.
The links and previous thread seem to be pretty cut and dry, not for artificial valves so I'm guessing that is both mechanical and the 3 months post op recommendation for tissue valvers to be anticoagulated.
But if you have a tissue valve and Afib then it's a different story.

I see if I read correctly from one of your previous posts you have a tissue valve and you have Afib, however it would appear you have been on Eliquis from day 1 after your AVR.. correct??

Which doesn't sound right unless there's something new happened in anticoagulation we all missed, or they are just making it up as they go along..
 

erricojj

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Definitely interested to hear what your cardiologist says.
The links and previous thread seem to be pretty cut and dry, not for artificial valves so I'm guessing that is both mechanical and the 3 months post op recommendation for tissue valvers to be anticoagulated.
But if you have a tissue valve and Afib then it's a different story.

I see if I read correctly from one of your previous posts you have a tissue valve and you have Afib, however it would appear you have been on Eliquis from day 1 after your AVR.. correct??

Which doesn't sound right unless there's something new happened in anticoagulation we all missed, or they are just making it up as they go along..
Yes, I have a tissue valve. I had 1 afib episode 2 days post op. That was 15 weeks ago. They put me on Amiodarone and Equilis to protect against further afibs. Have had no further afibs so my cardiologist had me stop Amiodarone about 1 month ago. He had me continue the Eliquis, intending to discontinue it after another 1-2 months. I think that is because the Amiodarone has a long 1/2 life and will dissipate slowly.

If the warning is meant to indicate that Eliquis is not suitable as a long term anticoag strategy but may still be used temporarily for tissue valvers with Afib, then it would be nice if they made that distinction.

I will update when I hear back from him.
 

Superman

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My understanding is that it’s contraindicated for mechanical valves, Bi-leaflet ticking pieces of carbon. Not tissue valves. When one takes anticoagulants for afib, it’s not to stop the afib. It’s to prevent clots from forming in the turbulence when the heart is out of rhythm. The other medication was to hopefully prevent the afib. Since tissue valves are not contraindicated for eliquis, you should be okay. But still confirm with your medical team and get a second opinion if you’re uncomfortable. Don’t take the word of some shmuck on the interwebs.
 

erricojj

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My mother was on Apixaban, another novel anticoagulant like Eliquis, for some years with her tissue valve, as she had a-fib.
Apixaban is the generic name for Eliquis, which is still on patent for some uses.

Found this 2019 article which contains this January 10, 2020 Update that I don't quite understand. I didn't realize that there are patients whose heart valves cause afib.

"Patients with prosthetic heart valves should not take apixaban. Apixaban was not studied in patients with atrial fibrillation caused by a heart valve problem."

 

pellicle

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Found this 2019 article which contains this January 10, 2020 Update that I don't quite understand. I didn't realize that there are patients whose heart valves cause afib.

"Patients with prosthetic heart valves should not take apixaban. Apixaban was not studied in patients with atrial fibrillation caused by a heart valve problem."

now, this is not medical advice as its well known that you should not even read forums on the internet, but I would incline to the view that there are two main streams of reasons for taking anticoagulants
  1. general stroke prophylaxis (especially when such is indicated by a series of TIA's or a non-transient Ischemic Stroke event or DVT event (or the like)
  2. prophylaxis in the case of a heart valve replacement
These two types have slightly different agendas: namely what is the cause of thrombosis. For its in the causes and the distance these are from the brain that the risks vary and what is likely to trigger it (platelet aggregation or exposure to tissue factor).

Type 1 is pretty much going to be for life (even if you have had a tissue valve)
Type 2 is perhaps temporary for those who have a tissue prostheis

So lets wander off the farm here and get random internet dude on ya'll

Firstly lets look at Coagulation (a good read to be had at Wikipedia), which says:

The mechanism of coagulation involves activation, adhesion and aggregation of platelets, as well as deposition and maturation of fibrin.

1668212885843.png


Platelets can be activated by the successive round trip whack on the arse obtained as they pass through the gates of the mechanical valve (and are exposed to opening and closing pressure jets). Much is written on this (not least of which is Yoganathan 2004, and K. Dumont et al 2007) and platelet activation numbers of 35 dyne x s/cm2 {where Dyne-second per square centimeter is a dynamic viscosity measurement unit}). To my knowledge non of these fluid dynamic processes has been studied or had thresholds identified in tissue prosthesis valves.

However its important to re-mention tissue factor which is emitted by damaged endothelia (and that occurs in heart surgery when the endothelia of the aortic artery is cut with a knife to slice out the old valve and when the needle penetrates and stitches are used to attach the new valve. This will continue to be a problem until after re-endothelisation occurs. This is why you're on blood thinners for 3 or so months after surgery no matter what.

So what can we make of this?

Well if your source of thrombosis is by platelet activation (virtually a certainty with a mech valve) you need something which will work on the areas above (factors II, VII, IX and X) to slow down this "Time for Thrombin to bunch up with fibrin.

If you have some other issue then simply stopping or slowing platelet activation will help (and that'd be aspirin or other antiplatelet stuff.

Where does this leave Apixaban? Well as that only works on X I suspect that it leaves it in the "insufficient" category of anticoagulants for a higher demand situation like mech valves.

Lastly, where does AF fit into this? I'm not sure if it generates sufficient dynes to cause platelet aggregations however it may cause the release of some tissue factor due to the "gyrations" it causes in the Atria while its having its little spastic episode between beats.

All this is good material to look at and to ask your actual qualified medical professional, because as I previously mentioned I'm just some random internet dude who's shuffled through the data. As a reminder of that I'll leave you with the advice from Bon Scott:

But how was I to know
That she'd been shuffled before?
Said she'd never had a royal flush
But I should have known

That all the cards were comin'
From the bottom of the pack
And if I'd known what she was dealing out
I'd have dealt it back

She's got the jack, she's got the jack
She's got the jack, and who knows what else

 

vitdoc

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Eliquis is not effective for anti coagulation of mechanical valves currently only warfarin is. So if one needs anti coagulation say for A. Fib then Eliquis is fine. No contraindication with tissue valves. If you are already taking warfarin for a mechanical valve and get A Fib you are already covered with warfarin and don't need any Eliquis or other novel anticoagulant.
I don't know if anyone has looked at the short interval that anti coagulation is used for tissue valves after surgery and whether there is a difference between different anti coagulation regimen in outcomes.
Also it is a bit of a stretch to say that the heart valve "causes" A. Fib. Heart disease causes A. Fib with the damage from the diseased valve leading to changes in the heart muscle which ultimately may be associated with A. Fib. Surgical trauma may induce A. Fib which more often than not is transient.
 

pellicle

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Also it is a bit of a stretch to say that the heart valve "causes" A. Fib. Heart disease causes A. Fib with the damage from the diseased valve leading to changes in the heart muscle which ultimately may be associated with A. Fib. Surgical trauma may induce A. Fib which more often than not is transient.
just wondering what you think of a (perhaps only my) theory that as valvular heart disease progresses, it causes unintended consequences in term of atrial resizing and even ventrical wall sizing, which results in stretching of the exterior (where there are nerves). This could then damage the myelin and cause problems in nerve triggering (and triggering of adjacent pathways) leading to the general reduction of proper synchronisation.
As I understood it the myelin isn't that flexible
 

vitdoc

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I am not an electrophysiologist but my understanding is that the electrical signals in A. Fib travel across the atrial tissue and not via nerve tissue. The pathway for the normal activation of the heart from the SA node to the AV node and to the right and left ventricles is specialized tissue but it is not mylinated.

The bundle of His comprises of a complex organization of cells, predominantly consisting of Purkinje-type cells, slender transitional cells, broad transitional cells, and varying amounts of pacemaker cells.[2] The Purkinje-type cells of the bundle of His are composed of randomly-oriented myofibrils, an abundance of mitochondria and Golgi apparatus, and a sporadic presence of two separate nuclei.

The pacemaker (P) cells are oval in shape and contain “sparse and randomly oriented myofibrils,” simple membranes, and trivial amounts of sarcoplasmic reticulum.[2]

The bundle of His is an elongated segment connecting the AV Node and the left and right bundle branches of the septal crest. It is approximately 1.8 cm long in an adult heart[4] and is primarily located deep within the dense connective tissue.

The bundle of His is characterized by longitudinal collagen partitioning histology, distinguishing it from the AV node.[2]

The intercalated discs in the bundle of His differ from the myocardial cells such that the discs in the bundle of His are oriented obliquely compared to the perpendicular alignment seen in the myocardium cross-sectional view. The bundle of His appears to have more “tongue-and-groove joints” compared to the “jagged perpendicular line” in the myocardium. Also, more tight junctions are found in the Purkinje cells of the bundle of His than in the intercalated discs of the myocardium.
[2]
 

pellicle

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I am not an electrophysiologist but my understanding is that the electrical signals in A. Fib travel across the atrial tissue and not via nerve tissue
Thanks

I would have thought that most of the atrial tissue was innervated.

I'll read that book reference, thanks 😊
 

Patrick2018

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Yes, I have a tissue valve. I had 1 afib episode 2 days post op. That was 15 weeks ago. They put me on Amiodarone and Equilis to protect against further afibs. Have had no further afibs so my cardiologist had me stop Amiodarone about 1 month ago. He had me continue the Eliquis, intending to discontinue it after another 1-2 months. I think that is because the Amiodarone has a long 1/2 life and will dissipate slowly.

If the warning is meant to indicate that Eliquis is not suitable as a long term anticoag strategy but may still be used temporarily for tissue valvers with Afib, then it would be nice if they made that distinction.

I will update when I hear back from him.
I have a tissue valve since 2018 and developed Afib shortly after surgery. I have always had a somewhat irregular heart beat. I tried warfarin initially and had problems regulating at various times and travel issues etc.. My cardiologist told me that Eliquis is an alternative. I have been on Eliquis for over two years with no problem. Can't find any data that says you should not take Eliquis specifically with a tissue valve. The data says not with an artificial heart valve.
 

oo0My_Valve0oo

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I have had Afib pre and post OHS with bio tissue valve. There has been no talk of treating the Afib. It is something that disqulifies me for a normal stress test. A normal stress test will produce a false negative because it is not designed to comprehend the Afib. I have not received medication at any point for it. I was told some people just develop it. They don't know why. I anticipate living with Afib for the rest of my life.

My friend's wife has heart problems and we were talking one day about Eliquis. He said, unlike Coumadin / Warfarin, you don't need regular lab tests. But my health organization doesn't offer a choice. With a bio tissue valve I was off anticoagulant medication within 3 months after surgery but if I could have avoided getting poked every week it would have been preferred.
 
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