Warfarin is scary stuff

Gilbert is a 58-year old high school science teacher.

When I first met Gil, he'd been having bouts of atrial fibrillation and had required various medications to suppress recurrences of the rhythm. However, because his rhythm proved somewhat difficult to control, his electrophysiologist (heart rhythm specialist) prescribed warfarin to reduce the risk of stroke. With atrial fibrillation, because of blood stagnation (in the left atrial appendage) in the heart, there is a stroke risk of approximately 8% per year. Warfarin reduces this risk substantially, to about 2%.

I met Gil because he had a cholesterol disorder. In my practice, the first step in gauging the implications of a lipid or lipoprotein disorder is to obtain a heart scan. If the heart scan score is zero, great. It means that we have plenty of time to treat the disorder since risk for cardiovascular events is near zero also; it means less intensive efforts less intensive efforts are necessary. But if the heart scan score is, say, 1200, then an aggressive approach in short order is required, since the risk for heart attack may as high as 20-25% per year, even in the absence of symptoms.

Gil's heart scan score: 787--high and posing a risk for heart attack of about 5-10% per year without preventive efforts. Gil did indeed prove to have a complex lipoprotein disorder, as well as high blood pressure, vitamin D deficiency, and several other potential contributors to coronary plaque.

Gil did just about everything right: He exercised, followed the recommended diet, achieved better than the Track Your Plaque 60-60-60, lost 18 lbs of abdominal fat.

Gil's rhythm stabilized for several months, only to have atrial fibrillation break through again. So Gil's electrophysiologist re-prescribed warfarin.

18 months later, Gil's 2nd heart scan score: 1410--a near doubling. Unsettling to Gil and to us, to say the least.

How can this happen in the face of perfect lipids/lipoproteins, correction of hidden causes like lipoprotein(a) and inflammation, along with a vigorous lifestyle effort?

I fear that the culprit might be warfarin.

Warfarin, better known by its brand name, Coumadin, may have some effects that intersect with the Track Your Plaque mission of reducing coronary plaque.

It is no secret that, beyond the obvious risk of bleeding from blood thinning, warfarin also may:

--Accelerate aortic valve calcification
--Accelerate calcification of the framework of the mitral valve (the mitral "anulus")
--Accelerate osteoporosis
--Induce an artificial situation of vitamins K1 and K2 deficiency.

The vitamin K1 deficiency is the route by which blood thinning is achieved. However, the K2 deficiency may have undesirable consequences, among which are the above list of various pathologic calcifications.

I therefore wonder if warfarin dramatically accelerated the coronary calcium that we track to gauge the progression of coronary atherosclerosis. One experience is hardly sufficient reason to sound the alarm. It is also difficult to pinpoint the cause of the explosive growth in Gil's coronary calcium specifically on warfarin.

That all said, I am quite certain it was the warfarin.

Unfortunately, some people are unavoidably committed to warfarin, such as those with specific genetic blood clotting disorders, prosthetic valves, prior deep vein thromboses and pulmonary emboli, etc.--serious reasons. Until an alternative emerges, warfarin remains a necessity for some people. (No, nattokinase is NOT an alternative, at least not one that would permit survival.)

My personal policy is that warfarin be used only when absolutely necessary and the gains markedly outweight the risks--including that of possible accelerated calcification of multiple sites.

Whether we will be able to get Gil off warfarin and potentially gain control over his coronary disease/plaque/calcium remains to be seen. I sure hope so.




Caraballo PJ, Heit JA, Atkinson EJ et al. Long-term use of oral anticoagulants and the risk of fracture. Arch Intern Med 1999; 159 (15): 1750–6. PMID 10448778.

Pilon D, Castilloux AM, Dorais M, LeLorier J. Oral anticoagulants and the risk of osteoporotic fractures among elderly. Pharmacoepidemiol Drug Saf 2004;13(5): 289–294.PMID 15133779.

Gage BF, Birman-Deych E, Radford MJ, Nilasena DS, Binder EF. Risk of osteoporotic fracture in elderly patients taking warfarin: results from the National Registry of Atrial Fibrillation 2. Arch Intern Med 2004; 166(2):241–246.PMID 16432096.




Copyright 2008 William Davis, MD

Comments (16) -

  • Anonymous

    4/19/2008 1:59:00 AM |

    Interesting--a good friend of mine had an angiogram 10 years ago to check a heart irregularity. Turned out he need a valve. the angiogram showed no stenosis or detatectable CAD. He had a mechanical valve put in and went on Comudin. Five years ago he had a heart attack with significant blockages. He has since had another heart attack. Your article would explain what happened.

  • Harry35

    4/20/2008 4:28:00 AM |

    There are other references that substantiate the negative effects of warfarin on the arteries. The effect of warfarin on coronary calcium score was investigated by Koos, et. al. in a study published in the American Journal of Cardiology, Vol 96, Issue 6, page 747 entitled "Relation of Oral Anticoagulation to Cardiac Valvular and Coronary Calcium Assessed by Multislice Spiral Computed Tomography," 15 Sept 2005. They found that the coronary artery calcium Agatston score of warfarin-treated patients with calcific aortic disease was about twice as high as that of similar patients not on warfarin (1561 vs 738). They concluded that "The results of our study have demonstrated that oral anticoagulation may be associated with increased valvular and coronary calcium in patients with aortic valve disease, presumably due to decreased activation of the matrix Gla protein."

    Also, there is a study by Price et. al. in Arteriosclerosis, Thrombosis, and Vascular Biology, 1998;18 pages 1400-1407,"Warfarin Causes Rapid Calcification of the Elastic Lamellae in Rat Arteries and Heart Valves." These rats were given Vitamin K to counteract the anticoagulant effects of warfarin, but they still experienced extensive calcification.

    Hopefully some of the new anticoagulants that don't interfere with warfarin, like Rivaroxaban, will be approved soon so that people in need of long-term anticoagulation won't have to rely on warfarin.

  • Anonymous

    4/20/2008 11:07:00 AM |

    I'm glad to see you are sometimes posting references at the bottom of your blog.  It doesn't help me so much, but it might be helping  doctors become believers.  

    Two former medical doctors, one is now a salesman, the other a researcher, have not shown  interest in TYP until last week for some reason.  One is from Germany, and when he was in town on  business i talked with him in person. he only had criticism for  TYP ideas.  The other from China didn't criticize but seemed to believe the supplements recommended were to similar to Chinese herbalist.  He would tell me that he wants western drugs not vitamin supplements for heart care.

    I don't know why but both doctors seem to have changed their mind on TYP last week.  The German doctor did not talk with me, he talked with a friend about buying the right kind of vitamin D to take for the TYP program.  Same change of heart happened with the Chinese salesman, as he contacted me wanting basic information on TYP.
    The Chinese friend will hopefully read this blog posting on vitamin K, and Warfarin, which I forwarded to him. I believe this is one of the medicines he takes.        

    The two do not know each other.    I don't know what happened to cause this turn around, but something did.

  • Mike

    4/20/2008 1:37:00 PM |

    Don't aspirin and Fish oil (omega-3s) also help thin the blood?

  • Anonymous

    4/24/2008 1:27:00 AM |

    I had a-fib until it was successfully treated at the Mayo Clinic by Dr Brady. Based on my experience I'd suggest Gil see an EP at one of the large centers with lots of experience ablating a-fib. You want an operator with +500 a-fib procedures under their belt.

    Three months after treatment, I was off warfarin.

  • Dr. B G

    4/26/2008 2:38:00 AM |

    EP fails most of the time (unfortunately). However, there appear to be many theories abounding that afib is a consequence of inflammation.... (ummm... just like CAD and heart disease).

    And guess what causes inflammation?

    Excessive carbs, insulin and diabetes/metabolic syndrome!

    http://www.ncbi.nlm.nih.gov/pubmed/15240964
    Sata N et al. C-reactive protein and atrial fibrillation. Is inflammation a consequence or a cause of atrial fibrillation?
    Jpn Heart J. 2004 May;45(3):441-5.
    PMID: 15240964

    Boos CJ, Lip GY.  Inflammation and atrial fibrillation: cause or effect? Heart. 2008 Feb;94(2):133-4. No abstract available.  PMID: 18195117

    Watson T, Kakar P, Lip GY. Cardioversion for atrial fibrillation: does inflammation matter? Am J Cardiol. 2007 Jun 1;99(11):1617-8. Epub 2007 Apr 17. No abstract available.

  • Dr. B G

    4/26/2008 2:38:00 AM |

    EP fails most of the time (unfortunately). However, there appear to be many theories abounding that afib is a consequence of inflammation.... (ummm... just like CAD and heart disease).

    And guess what causes inflammation?

    Excessive carbs, insulin and diabetes/metabolic syndrome!

    http://www.ncbi.nlm.nih.gov/pubmed/15240964
    Sata N et al. C-reactive protein and atrial fibrillation. Is inflammation a consequence or a cause of atrial fibrillation?
    Jpn Heart J. 2004 May;45(3):441-5.
    PMID: 15240964

    Boos CJ, Lip GY.  Inflammation and atrial fibrillation: cause or effect? Heart. 2008 Feb;94(2):133-4. No abstract available.  PMID: 18195117

    Watson T, Kakar P, Lip GY. Cardioversion for atrial fibrillation: does inflammation matter? Am J Cardiol. 2007 Jun 1;99(11):1617-8. Epub 2007 Apr 17. No abstract available.

  • Dr. B G

    4/27/2008 5:48:00 AM |

    Dear Anonymous,

    I hope your physician friends become as enamored with TYP as you are Smile  
    This is the 'trickle up' effect!

    Thanks for your endorsements and support!

  • Dr. B G

    4/27/2008 5:48:00 AM |

    Dear Anonymous,

    I hope your physician friends become as enamored with TYP as you are Smile  
    This is the 'trickle up' effect!

    Thanks for your endorsements and support!

  • Anonymous

    7/24/2008 12:07:00 AM |

    What if Gil abstained from consuming all (plant source) vitamin K1 rich foods and supplimented with vitamin K2 at a dose that would make his INR managable?  Would that at least help stop his calcium score from going up further?

    Also, with a better than 60/60/60 lipid profile, won't the more dangerous soft "unstable" plaques and small LDL particles still remain minimized?  And if that's true, would that make Gil, and people like him, be a rare exception to the "heart scan score" being the "golden standard" to predict future heart attack risk?

  • phuli cohan

    2/20/2009 9:22:00 PM |

    Vitamin K2 deficiency can be safely corrected while on warfarin, there is an excellent article about how to do this safely ( Pharmacotherapy 2005;25:1746-1751).  There are also specialty labs that measure K2.  All cardiac patients should maintain normal levels of K2

  • buy jeans

    11/3/2010 3:46:34 PM |

    Gil's heart scan score: 787--high and posing a risk for heart attack of about 5-10% per year without preventive efforts. Gil did indeed prove to have a complex lipoprotein disorder, as well as high blood pressure, vitamin D deficiency, and several other potential contributors to coronary plaque.

  • yeast infection cures

    2/22/2011 6:01:05 AM |

    wow. lastly, I found something useful for my paper to write down about. that is fascinating and helps me with extra research in the future. Glad I found this blog.Thank you. And I do hope you'll develop some of your concepts about this matter and I'll positive come again and browse it. Thanks for the effort and time.

  • Jeorjette

    6/12/2011 1:48:54 PM |

    I had open heart surgery 14 months ago to repair the mitral valve of a infection that had attached itself as a vegetation. I ended up having AF and now on warfarin. I was told you can't have this and can't have that. Rubbish. For over a year I have self medicated myself with 40mg of Vitamin K in the form of stem enhance followed with superabsorable CoQ10, gamma E, and many other high quality vitamins, lots of anti-oxidents and growth hormone releasing agents in the form of amino acids. Also L-Arginine and nician. I am doing extremely well.
    Not only that. I also mix raw cabbage, sweet potato, beetroot, celery, broc ,tumeric, carrot and more
    I am taking warfarin but the trick is balancing and consistancy and you can do extremely well regardless of the set back. Don't say no. Don't sit and die. Think beyond the square

  • Jeorjette

    6/12/2011 11:26:10 PM |

    Secondly, warfarin does do damage. Use natural products to counterbalance these. Using amino acid stacks you can also trigger your own growth hormone, not only to counterbalance the damage warfarin does but it also excel the rest of the body. Anti-oxidents should also be taken in a wide spectrum like Acai Berry, Vit C, CoQ10,gamma E, Nanoresveratrol, Calcium complex, Omega 3. Whey powder, colstrum, Stem cell enhance
    most products  www.life-enhancement.com  and www.lef.com  also look at pituiatry support to start growth hormone release

  • Hal

    4/19/2012 4:01:44 PM |

    How does Pradaxa fair in this tail?  I have AFib and recently switched from warfarin to Pradaxa.  Well on Warfarin I did (and on Pradaxa will continue to) supplement with K2 but it appears that this was at lower levels than recommended here.  I plan on increasing my K2 intake.

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A stent--just in case

A stent--just in case

Burt came to me last week. He'd received a stent a few months earlier. He'd been feeling fine except for some fatigue. A nuclear stress test proved equivocal, with the question of an abnormal area of blood flow in the bottom (inferior wall) of the heart.

"The doctor said I had a 50% blockage. Even though it wasn't really severe, he said I'd be better off with a stent, just in case."

Just in case what? What justification could there be for implanting a stent "just in case"? (The artery that was stented did not correspond to the area of questionable poor blood flow on the nuclear stress test.)

Just in case of heart attack? If that's the case, what about the several 20 and 30% blockages Burt showed in other arteries? The cardiologist was apparently trying to prevent the plaque "rupture" that results in heart attack by covering it with a stent. Why stent just one when there were at least 7 other plaques with potential for rupture?

That's the problem. And that's why stents do not prevent heart attack (unless the stent is implanted in the midst of heart attack, when the rupturing plaque declares itself.) Of course, when no plaque is in the midst of rupturing, as with Burt, there's no way to predict which plaque will do so in future. Since only one plaque was stented, there is a 7 out of 8 chance (87.5%) that the wrong plaque was chosen. And that's assuming that there aren't plaques not detected by catheterization angiogram; there commonly are. The odds that the right plaque was chosen would be even lower.

In other words, stenting one blockage that is slightly more "severely blocked" in the hopes of preventing heart attack is folly. If it's not resulting in symptoms and blood flow is not clearly reduced, a stent can not be used to prevent plaque rupture. A stent is not a device to be used prophylactically. It is especially silly when an approach like ours is followed, since plague progession is a stoppable process.

Note: This issue is distinct from the one in which symptoms and/or an abnormal stress test show clearly reduced blood flow and flow is restored by implantation of a stent. While some controversies exist here, as well, a stent implanted under these circumstances may indeed provide some benefit.

Comments (3) -

  • Anonymous

    3/26/2007 12:45:00 AM |

    Interesting blog.  I have a question: would you be able to offer some comments on Dr. Ornish reversal programme and low fat vegan diets (in reversing CHD), based on your professional experience?

    We are having a little discussion about various pros and cons of various therapies and dietary approaches on the Web MD forum:

    http://boards.webmd.com/webx?14@1016.MAjDbu7Matv.0@.5987f44c

    We would really welcome you and would greatly appreciate some professional comments.  Sincerely,
    Stan Bleszynski (Heretic)

  • Dr. Davis

    3/26/2007 11:36:00 AM |

    Super low-fat diets, while an improvement over a conventional modern American diet of high saturated fat and processed foods, seriously exagerrate the small LDL particle pattern that is among the most powerful causes known of heart disease. It also reduces HDL and raises triglycerides, sometimes substantially. Dr. Ornish would argue that these are inconsequential changes, since his patients regress. Unfortunately, the methods he uses to gauge regression of atherosclerotic plague are flawed: angiography and nuclear imaging. Both can be envisioned as measures of flow, not of atherosclerotic plaque. Only CT heart scans or intracoronary ultrasound actually measure artery plaque. I tell my patients that, if you want heart disease, follow the American Heart Association diet. If you want heart disease and diabetes, follow Dr. Ornish's diet.

  • Cindy

    3/28/2007 12:47:00 AM |

    I know several people who have gone for a "routine" check with a cardiologist, sent for an angio, and ended up with at least 1 stent. (NO symptoms prompted these visits, just "high cholesterol".

    I also know a couple of people that have 9, 10, or more stents!

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