We are going to discuss blood thinner medications for Afib and bleeding risk. Does the risk of your blood thinner medication outweigh the benefits?


Blood thinner medications like Eliquis, Xarelto, warfarin, and others are commonly prescribed for those with Afib because these medications lower the risk of stroke for those with Afib by about 70%.


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As we talked about in the Blood Thinner Medications for Afib - Do I Really Need Them? Video, if you have enough risk factors for stroke and you have Afib, blood thinner medications are generally recommended.

However, all decisions about blood thinner medications also have to consider the risk of these medications - namely, the increased risk of bleeding.

In other words, the benefits of the blood thinner - reducing stroke risk - have to be balanced by the risk of bleeding.


Why blood thinners might NOT be recommended

Sometimes blood thinners are not recommended - even when the stroke risk is high because of excessive risk of bleeding. Examples of situations when bleeding risk may be too high include someone prone to frequent falls, has severe anemia, or a very low platelet count, has active bleeding, a recent brain bleed, or a mass in the brain.

A more specific way to assess bleeding risk is to calculate what is called the HAS-BLED score.


The HAS-BLED score takes into account nine factors that influence bleeding risk. Here is a link to an online calculator.

  • If the score is 0 - the risk of bleeding is about 1% per year
  • If the score is 9 - the risk of bleeding is over 10% per year.


When is a HAS-BLED score too high to recommend blood thinner medication? Well, the cut off is clinical judgment, but when the HAS-BLED score is four or higher, a physician may consider alternatives to blood thinner medications.


Watchman device

I do want to mention that there is a device and procedure called the Watchman device that is designed to lower the risk of stroke for those who are at high risk for bleeding on blood thinner medication and also at high risk for stroke if not on blood thinner medicine.

This device obstructs a structure in the heart called the left atrial appendage, where blood clots are most likely to form in those with Afib. Although the device has been approved, at this time, the research data is still not convincing to all cardiologists.

Whether the procedure is better than no blood thinner medication is still controversial among some cardiologists. However, future research will hopefully clarify this question.



Lastly, I want to mention two other medicines that are often talked about in the prevention of stroke and Afib. Specifically, aspirin and clopidogrel (or Plavix). These are also considered blood thinner medications by some, although they work in a completely different way than medications like Eliquis and warfarin. They block platelets from coming together, which is part of the blood clotting process.

As attractive as these medicines may be for stroke prevention, they likely don’t work well. Aspirin provides little, and probably no benefit in stroke prevention in Afib. Combining aspirin and clopidogrel (or Plavix) has shown a slight decrease in stroke in those with Afib but at a high risk of bleeding. Neither of these medications is recommended for stroke prevention in Afib in general.


In summary

Stroke prevention in Afib is crucial. Our most effective way to prevent stroke in Afib is with blood thinner medications, but those benefits need to be balanced by the risk of bleeding on these medications. This critical discussion should be between you and your doctor to determine what’s the best strategy for you.


Source: Calculate HAS-BLED Score


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