Oral anticoagulant therapy to reduce the risk of stroke Information for patients from the Stroke Department Patient name:... Anticoagulant medication:... You are being given this information sheet because you have been prescribed a blood thinning (anticoagulant) drug. This information leaflet will explain why you have been started on this medication, give you information about the drug you are taking, and clarify how this will help reduce your risk of having a stroke. What is atrial fibrillation? Atrial fibrillation is often referred to as AF; and is a common heart rhythm disturbance, making your heartbeat irregular. As a result your heart will not pump the blood around your body as well as it should. AF affects over 980,000 people in the UK and is more common in older people, it can increase your risk of stroke by up to five times if the right treatment is not in place. What are the symptoms of AF? Symptoms of AF can vary; some complain of a fast heartbeat, dizziness, shortness of breath, or chest pain. Other people with AF do not experience any symptoms at all. We care 1
How is AF detected? AF can be detected by a healthcare professional through checking your pulse, and usually an ECG (electrocardiogram) which traces the rate and rhythm of your heart. These tests were performed during your hospital visit. Why does this increase my risk of stroke? A stroke happens when the blood supply to part of your brain is cut off. Due to the irregularity of your heartbeat, your heart may not have a chance to relax and empty properly before filling up with blood again. Blood can collect and pool, which increases the risk of blood clots forming. If blood clots form in your heart, there is a risk they can travel in your bloodstream towards your brain. If a clot caused a blockage in an artery leading to your brain, it could cause a stroke or transient ischemic attack (mini stroke or TIA). What treatment do I need to reduce my risk of stroke? The main group of drugs used to treat AF are anticoagulants. These thin the blood in order to stop clots from forming, and can reduce the risk of stroke by 60%. There are a number of different blood thinning drugs that can be used, these include Apixaban, Dabigatran, Edoxaban, Rivaroxaban, and Warfarin. Will I have to stay in hospital? Treatment can be started as an outpatient; however while you are in hospital we may find that you have an irregular heartbeat, therefore your treatment will be started immediately. Your medications will be managed by your GP after your discharge from hospital. Are there any alternatives? Historically Warfarin has been the only anticoagulant drug recommended to reduce your risk of stroke due to AF. However, in 2012/2013 a new group of novel oral anticoagulants (NOACs) were approved for stroke prevention. These are called Apixaban, Dabigatran, Edoxaban, and Rivaroxaban; and are an alternative to Warfarin. Many patients choose them as a preference as they do not require the same level of blood test monitoring as Warfarin. However with all of these drugs, your GP will occasionally do a blood test to monitor your kidney function. The choice of which drug is best for you will depend on your medical conditions, and will have been decided following a conversation between you and your doctor. 2
What do I need to know about my medication? Each of the NOAC drugs work slightly differently; therefore the specific anticoagulant drug that you are prescribed will depend upon your clinical history, and individual need. This will be assessed by the prescribing doctor who will start the drug they feel would be most suitable for you. Please read below the information about the drug you are taking. Warfarin Warfarin works by slowing down the way vitamin K is made, which then slows the making of prothrombin (a protein that helps your blood to clot). Warfarin is given as a tablet, and the dose may vary as it needs to be altered to suit your blood clotting levels. If you are on Warfarin you need to have regular blood tests to check how long it takes for your blood to clot, this maybe at a specialist anticoagulation clinic at the hospital or your GP surgery. This will make sure your blood does not become too thin, which could put you at risk of bleeding. When you are first prescribed Warfarin, you will require frequent blood tests, however once your levels are stable you will need to attend an anticoagulation clinic less regularly. When taking Warfarin, blood clotting levels can be affected by some foods that are rich in vitamin K; these include cranberry juice (which should be avoided), green leafy vegetables, brussel sprouts, broccoli, and mature and blue cheeses and it is suggested that these are taken in moderation. Alcohol should also be kept to a minimum as it makes your blood thinner, which will increase your risk of bleeding. Some types of medication can react with Warfarin and affect your blood clotting levels, these can include antibiotics, antibacterials, antifungals, antidepressants, analgesics, and statins. Your GP or pharmacist can give you advice with this before taking it. Homeopathic and over the counter medicines may also interact with Warfarin so discuss any of these medicines with your pharmacist. Any change in lifestyle or wellbeing may also influence the effectiveness of Warfarin therapy, such as going on holiday to a place in which there is a big change in climate or diet, if you are unwell (for instance if you have flu, sickness, or diarrhoea), or start any new medication. Side effects of Warfarin may include bleeding, nausea or vomiting, diarrhoea, skin rashes, hair loss, and purplish toes. The effects of Warfarin maybe reversed by Vitamin K. 3
Dabigatran Dabigatran works by attaching itself to thrombin (a blood component), making the blood less likely to form a clot. It is given as a tablet, and prescribed as a regular dose taken twice a day. If you take this drug you will need occasional blood tests by your GP to make sure your kidneys are working well. Some medicines may not work well with Dabiatran: some antibiotics, anti-arrhythmic drugs, anticonvulsants, aspirin, and anti-inflammatory medication. The herbal remedy St John s Wort can also interact. Your GP or pharmacist can give you advice with this before taking it. Side effects of Dabigatran may include bleeding, diarrhoea, indigestion, nausea, and stomach pain; if you have unusual bruising or unexpected pain you should speak to your GP urgently. If you suffer severe or uncontrollable bleeding, or headaches accompanied by dizziness or limb weakness, go directly to your local accident and emergency (A&E) department. Rivaroxaban Rivaroxaban works by blocking Factor Xa in the blood, making it less likely to clot. It is given as a tablet, and prescribed as a regular dose once a day it is advisable to take this at the same time every day. Rivaroxaban sometimes interacts with other types of medication such as antifungal agents, anticonvulsants, heparin, anti-inflammatory medication, medicines that affect blood clotting, and herbal remedies such as St John s Wort. Your GP or pharmacist can give you more advice on this if required. Side effects of Rivaroxaban include bleeding, constipation, diarrhoea, dizziness, and fainting; if you have unusual bruising or unexpected pain, minor bleeding (such as regular nosebleeds or bleeding gums), or cuts that take a long time to heal, you should speak to your GP urgently. If you suffer severe or uncontrollable bleeding, or headaches accompanied by dizziness or limb weakness, go directly to your local A&E department. Apixaban Apixaban makes the blood less likely to clot by blocking a protein Factor Xa in the blood, which plays a key role in the blood clotting process. It is usually prescribed as a regular dose, twice a day, it is advisable to take this medication at the same time each day. Apixaban may interact with antifungal agents, anticonvulsants, anti-inflammatory medication, medicines that affect blood clotting, and herbal remedies such as St John s Wort. Your GP or pharmacist can advise you on this if required. The main side effect of Apixaban is bleeding. Seek urgent medical attention from your local A&E department if you notice any of the following symptoms which may mean you are allergic to Apixaban: swelling of the face, mouth, lips or tongue, or difficulty breathing; or if you have severe or uncontrollable bleeding; or a severe headache accompanied by dizziness or limb weakness. 4
Edoxaban This medicine helps to prevent blood clots from forming. It works by blocking factor Xa, which is an important component of blood clotting. Like other similar medicines, Edoxaban may cause bleeding.it is prescribed as a regular dose once a daily. Edoxaban may interact with some medicines for fungal infections, medicines to treat abnormal heart beat, some antibiotics, medicines to prevent organ rejection after transplantation, anti-inflammatory and pain relieving medicines, some medicines for treatment of epilepsy, and some herbal remedies such as St John s Wort. If you experience any bleeding event that does not stop by itself or if you experience signs of excessive bleeding (exceptional weakness, tiredness, paleness, dizziness, headache, or unexplained swelling) consult your doctor immediately. If you suffer severe or uncontrollable bleeding, or headaches accompanied by dizziness or limb weakness, go directly to your local A&E. If you are experiencing a symptoms with your medication, please discuss with your GP; however if you are unsure who to contact in a potential emergency please ring NHS 111 for further advice. If you need a medical or dental procedure, your anticoagulant medication may need to be stopped beforehand. This decision should be made by your doctor or dentist who will assess the potential risks of having the procedure and stopping your medication. What do I need to change in my life? Anticoagulant therapy is aimed to thin your blood, therefore you should be aware of the increased risk of bleeding and bruising in everyday life. It is advisable to avoid contact sports or martial arts; however non contact sports are fine provided you remember that any injury sustained is likely to result in greater bleeding or bruising. Cuts may take longer to stop bleeding, if bleeding does not stop you should attend a minor injuries unit. Head injury/bumps to the head may cause internal bleeding that cannot be seen. If more than a very minor bump it is advisable to discuss with your GP or ring NHS 111. For minor bumps, monitor for drowsiness, feeling dizzy when walking or standing up, vomiting, worsening headaches, problems with vision such as blurring, changes in behaviour, fits/convulsions. If any of these symptoms happen you must attend your nearest A&E Department straight away. Nose bleeds - carry out normal first aid (cold flannel/compress on bridge of nose/forehead), lean your head forward and pinch the bridge of the nose firmly for at least 10 minutes. If nose bleed persists seek urgent medical advice via your GP or 999. If you need any medical advice or support, make sure you inform the staff you are taking anticoagulant tablets. What do I do if I am having problems with my medication? Please ensure you read the leaflet that comes with your anticoagulant medication. If you have concerns or questions about your medications, talk to either your GP or your local pharmacist. It maybe a simple problem that can be resolved, or there maybe something we can do to help. Never just stop taking your medication, even if you feel unwell. Always contact your GP for advice stopping medication suddenly can be dangerous. In a medical emergency, always call 999. 5
Where can I get further information about AF and stroke prevention? Atrial Fibrillation Association The Stroke Association 24 hour helpline: 01789 451837 Telephone: 0303 3033 100 www.atrialfibrillation.org.uk www.stroke.org.uk National Clinical Guidelines for the Management of Atrial Fibrillation: NICE Guideline CG180 (2014) Guidelines for the Management of Atrial Fibrillation: European Society of Cardiology (2010) National Clinical Guidelines for Stroke (4th Ed): Royal College of Physicians (2012) Any complaints, comments, concerns, or compliments If you have other concerns please talk to your doctor or nurse. Alternatively please contact our Patient Advice and Liaison Service (PALS) on 01227 783145 or 01227 864314, or email ekh-tr.pals@nhs.net Further patient information leaflets In addition to this leaflet, East Kent Hospitals has a wide range of other patient information leaflets covering conditions, services, and clinical procedures carried out by the Trust. For a full listing please go to www.ekhuft.nhs.uk/patientinformation or contact a member of staff. After reading this information, do you have any further questions or comments? If so, please list them and bring to the attention of your nurse or consultant. Would you like the information in this leaflet in another format or language? We value equality of access to our information and services and are therefore happy to provide the information in this leaflet in Braille, large print, or audio - upon request. If you would like a copy of this document in your language, please contact the ward or department responsible for your care. Pacjenci chcący uzyskać kopię tego dokumentu w swoim języku ojczystym powinni skontaktować się z oddziałem lub działem odpowiedzialnym za opiekę nad nimi. Ak by ste chceli kópiu tohto dokumentu vo vašom jazyku, prosím skontaktujte nemocničné pracovisko, alebo oddelenie zodpovedné za starostlivosť o vás. Pokud byste měli zájem o kopii tohoto dokumentu ve svém jazyce, kontaktujte prosím oddělení odpovídající za Vaši péči. Чтобы получить копию этого документа на вашем родном языке, пожалуйста обратитесь в отделение, ответственное за ваше лечение. We have allocated parking spaces for disabled people, automatic doors, induction loops, and can provide interpretation. For assistance, please contact a member of staff. This leaflet has been produced with and for patients Information produced by the Stroke Department Date reviewed: March 2017 Next review date: July 2019 RK/EKH185 6