The ‘Cardiac Conveyor Belt’: My Experience

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I didn’t coin the term. It was my cardiologist who said the process wasn’t a ‘conveyor belt’ but someone must ahve thought so. It sure looked like a conveyor belt to me, so I went digging. What I found was a major lawsuit, a curious score and serious side effects that made it easier to decide to hop on the conveyor belt or not.

No Pulse

About three years ago, my pulse was so irregular, I couldn’t check it after exercising. I took no notice until I saw a look of alarm on Tracey’s face when she couldn’t find it.

It turned out I had Atrial Fibrillation (A Fib, they call it, a bit like A Rod, the nickname for tennis player, Andy Roddick). A Fib rears its head when the upper chambers of the heart stop working. I didn’t have terrifying episodes like the racing heartbeat you can hear in your ears. For me, it was mostly fatigue and dizziness. The most common symptoms of A Fib are irregular pulse, heart fluttering and palpitations.

A Fib isn’t trivial; it’s linked to 25% of strokes, the ischemic ones where blood clots lodge in the brain. Warfarin used to be prescribed to prevent clotting; these days the drugs of choice are Direct Oral Anticoagulants (DOAC), also known as (clotting) Factor Xa inhibitors. ‘Xarelto’ from Janssen and Bayer is one of them; ‘Eliquis’ from Bristol-Myers Squibb is another.

The Answer: ‘Xarelto’

My GP prescribed Xarelto (generic name rivaroxaban), the market leader, which is also prescribed to prevent deep vein thrombosis (DVT), pulmonary embolism, and strokes for people at risk. I decided to look into it.

The first thing that popped up was that Janssen and Bayer were fending off some 25,000 lawsuits from patients or partners of patients who had suffered strokes, and uncontrollable bleeding causing death or serious injury.

That’s not all of it. The Mayo Clinic has a full list of adverse effects; below are the most common:

  • Stroke
  • Retinal hemorrhages
  • Death
  • Epidural haematoma
  • Intracranial hemorrhages
  • Pulmonary embolism
  • Hemoglobin decrease
  • Gastrointestinal hemorrhages
  • Deep vein thrombosis
  • Bleeding around the spine, which can leave you paralyzed. 
  • Adrenal bleeding.

The Antidote: Andexxa

The bleeding problem became controllable when an antidote called Andexxa became available in 2018, some seven years after Xarelto was first approved by the FDA. In other words, patients took Xarelto to avoid blood clots and then took Andexxa to avoid the clots without the bleeding.

If you check the Xarelto pack insert today, it hasn’t changed. It still says: ‘Risk of bleeding: XARELTO can cause serious and fatal bleeding. An agent to reverse the activity of rivaroxaban is available’.

‘Risk of bleeding: XARELTO can cause serious and fatal bleeding. An agent to reverse the activity of rivaroxaban is available’.

Pack Insert for Xarelto (Rivaroxaban)

Neither my GP nor the chemist filling the prescription mentioned any of the side effects or the legal action.

After the Dust Settled

The law suits were finally settled in 2019 for US$775 million, about a year before I was prescribed the drug.

Xarelto has been quite a success story, financially, at least: Fierce Pharma reported that Xarelto sales in the U.S were US$2.5 billion the year before, while Bayer’s sales of Xarelto internationally were over US$4 billion. Not a blockbuster drug, but popular for those conditions and still being prescribed.

When I checked the NNT (number needed to treat before one patient gains a benefit), I was in for a shock: 433 for stroke and 629 for thrombo-embolic event (see below). That is, less than a 0.2% chance of either being prevented.

I shook my head: why would anyone take a drug that might cause uncontrolled intestinal bleeding and death if there were a less than 1% chance it would prevent a stroke or thrombosis? Not me, for sure. I decided to check into safer alternatives; see below. (More on what the numbers mean in our post here.)

‘Don’t Read Tolstoi’

Three years later, I felt that the fatigue and dizziness of A Fib were getting worse, so I decided to see a cardiologist. He organized a Coronary Artery Calcium (CAC) scan, an ultrasound and a Holter meter that would track my ticker’s performance for 24 hours.

When we sat around his desk to discuss the results, he announced that my CAC score was over 1,000. The blood in my face drained, as I remembered the words of Sydney cardiologist, Ross Walker, who introduced CAC scoring Down Under years ago: ‘if your CAC score is over 400, don’t read Tolstoi.’

Now, the cardiologist sitting opposite said I should arrange an urgent angiogram with him. He added that, given the amount of calcium in my arteries, there were bound to be blockages that would require stents, so I’d need to give approval for these before the angiogram.

..if your CAC score is over 400, don’t read Tolstoi.’

Dr Ross Walker, Cardiologist

‘Not a Conveyor Belt’

When I asked him about the maintenance program afterwards, he rattled off a bunch of drugs he’d put me on – Xarelto, a beta-blocker, a calcium channel blocker, an aspirin and a statin – for the rest of my life.

Tracey and I looked at each other in disbelief, both thinking: ‘This is 2021; how could he be prescribing Xarelto plus a bunch of old drugs from decades ago?’ He also hadn’t asked me a single question about my diet, my exercise regime, my usual blood test results, my family history of heart disease. Nothing.

He did say that he was the preferred specialist for this sort of work and, by good fortune, he could fit me in in two weeks. Reassuringly, he said: ‘This is not a conveyor belt, you know. You can stop or get off at any time’.

Tracey and I exchanged more glances, then she asked, ‘Do any of your patients ever say they’d like to think it over?’ She can be quite direct at times. He said ‘No. Never’ to which she replied ‘We do.’

This is not a conveyor belt, you know. You can stop or get off at any time’.

The stent cardiologist who will remain unnamed

We hadn’t thought about it at the time, but my selection of specialist had determined the next step; I saw a stent guy so his only answer he had was stents, and drugs. What I needed was a cardiologist who didn’t specialsie in any procedure at all. To my delight, it turned out to be the same Ross Walker.

Treadmill This Time

I ended up in Walker’s clinic on Sydney’s North Shore, seeing his associate, Cathy Smillie, who spent 45 minutes quizzing me about my health. Then, she put me on a treadmill to check my ticker’s performance in the real world.

She concluded that, on the basis of this, an investigatory angiogram was in order. With this degree of thoroughness, this time I was happy to agree.

Smillie sent me to a specialist nearby, who stopped the procedure soon after it started, stating (in words made famous by ex-PM Scott Morrison): ‘Nothing to see here’. How come? The calcium in my arteries was stable and evenly distributed; apparently it’s the unstable stuff that can dislodge and travel to dangerous places like the brain. In a way, my arteries had been fortified by calcium.

‘Nothing to see here.’

My angiogram cardiologist, despite my CAC Score of over 1,000.

A Quick Reboot

I was back on the North Shore a few weeks later, for a cardioversion procedure, designed to reboot my heart, to jolt it back into normal rhythm and so reverse the A Fib. It was quick and pain free (but alarming for Tracey and the family), and the cardiologist declared it a success. As soon as he’d left, though, my pulse was bouncing around again.

One benefit of the cardioversion was that it told Smillie that the next option to reverse A Fib – cardio ablation – probably wouldn’t work; I’d left it too long and my heart had adjusted to the new reality. That was probably just as well, because ablation is way more scary than what I’d had so far: it involves burning off some of some of the confused electrical wiring on the outside of the heart.

It’s a pity the first GP hadn’t suggested my seeing a cardiologist four years before; back then, the cardioversion may have worked.

The Sound of Silence

Why am I telling you all this?

Because it illustrates this point: we can’t expect our doctors and chemists to have read the pack inserts of every drug they handle, or to track all developments after every drug’s approval. They don’t. They can’t. They’re simply too overworked these day. But, cardiologists, specialists in heart matters, definitely should be checking the most popular heart medications.

Regardless, someone has to do be checking.

In my case, it’s me: I check every drug before I get a prescription filled, but it doesn’t happen often. Apart from being prescribed a statin when I turned 60, Xarelto was the first drug prescribed for me for life, and checking it out was more than worth it.

Yet, if you just checked government and patient support websites, you won’t find any of what I found.

In the case of Xarelto, government website Healthdirect says:’ If you are over 65 years of age, there may be specific risks and recommendations for use of this medicine. Please discuss your individual circumstances with your pharmacist, doctor or health professional. For more information read our page on medication safety for older people.’ Not a word about adverse events. Australian Prescriber offers some preliminary info that’s over 10 years old and hasn’t been updated. 

myDr is the one local site that provides a detailed and up-to-date rundown of this drug.

What Could Have Happened?

I won’t speculate but American cardiologist Eric Topol, wrote a book about it called The Creative Destruction of Medicine. In it, he describes a patient who came to him at the end of the cardiac conveyor belt.

In just four months, this guy had gone from being a fit, lean, active 58-year-old with no history or symptoms of heart disease, to debilitated, depressed and in pain, via a CAC score of 710, five stents and a drug regime identical to mine, except that mine also had a calcium channel blocker. (Read his book excerpt in Scientific American here.) Topol sums up the situation with the quote below.

To a man with a hammer, a lot of things looks like nails that need pounding. Surgeons are notorious for a similar bias: when it doubt, cut it out.

Dr Eric Topol, Cardiologist, Scripps Research Institute

That sounds a lot like what I experienced with the first cardiologist; all he did was stents.

Are There Other Options?

For almost a decade now, I’ve been eating food high in omega-3 fatty acids, mainly to control my psoriasis. Digging around for heart information, I discovered that this regime has other benefits.

This recent paper in the journal Open Heart says ‘clinical studies in humans clearly show that marine omega-3s provide anti-platelet effects, and a meta-analysis of 15 randomised controlled trials in humans has confirmed that omega-3 fatty acids inhibit platelet aggregation.’ That’s what Xarelto does, but the stent cardiologist scoffed when I suggested this. Fish oil also helps to prevent blood clots, but not by thinning the blood, but by making the blood less sticky

Another supplement I’ve taken for years is grape seed extract. It makes swollen feet and ankles caused by Chronic Venous Insufficiency (CVI) simply vanish. It’s such an effective anticoagulant, we’re warned not to take it if taking anticoagulants. It’s also as cheap as chips and has no side effects. Here’s a snapshot of grape seed extract from MedicalNewsToday, and another from Memorial Sloan Kettering that includes benefits for atherosclerosis.

It seems like there is a lot of evidence for alternatives or deviations from the cardiac conveyor belt. I go into this more in my upcoming eBook: Heart Disease: Take Back Control. To find out when (and a heap of other stuff) get updates below.

…marine omega-3s provide anti-platelet effects, and …omega-3 fatty acids inhibit platelet aggregation.

Open Heart Journal

I’m not a doctor, cardiologist or expert in anything medical, so I certainly won’t suggest what is best for you. What I will suggest is that you find out as much as you can before you make decisions about your precious heart.

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Kim Brebach

Kim Brebach

Hi, I’m Kim Brebach, boomer, information researcher, technical writer and Joiner of Dots at M&M. In my spare time, I review wines and love to cook.

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