Jim’s Tech Talk
By Jim Langley
Longtime RBR reader and frequent contributor Stephen Weeks reached out for some help with a recent health issue. Steve is 74. A dentist by trade, he lives in Mundelein, Illinois, which is a village about 40 miles northwest of Chicago. Steve’s a dedicated cyclist who commutes to work even in the winter. He asked if I would share the following emails with you and requested your input. Here’s his story:
Steve’s First Email
“Hi, Jim,
Last time I emailed you it was to describe my experience with a long-term heart monitor to settle a disagreement I had with my internist. The good news, which came to my aid later, was that I don’t have any significant cardiovascular issues other than running a high heart rate at times.
Well… in October my wife and I drove out to Boston to see our daughter and son-in-law. We made the trip over three days. Somewhere in that time I began to have some chest pain. Since I knew I was in pretty good shape CV-wise, I wrote it off as muscle cramps due to position in the car. It was a sharp pain on the side of my rib cage. Anyway, by the second night in Boston I realized I had to seek help or I wasn’t going to be able to sleep. I wound up in the hospital with a pulmonary embolism. Luckily, it wasn’t too bad, but it took a day out of my visit. I left the hospital on Eliquis, an anticoagulant (“blood-thinner”).
Here’s the relevance to cycling: my internist and another doc have advised me not to ride bicycles, especially not in traffic. The risk they cite (unfortunately real) is that if I suffered internal bleeding in a crash, I might have a worse outcome because my blood wouldn’t clot. The worst case scenario would be a “brain bleed.” Now, I’ve fallen off my bike maybe 3 times in the last 20 years, and I’ve never hit my head, so I think the brain bleed is a low risk. And I’ve never been hit by a car, so the likelihood of internal injury is likewise low. But not “zero.”
I have “Road ID” tags on my heart rate monitor and my wristwatch https://www.roadid.com/, so a first responder would be able to see my medical history if I were unable to provide it. I’m also limiting my riding to trails (prepared crushed limestone) out of an “abundance of caution.” Actually, I’m not riding at all for a while because my wife had a knee replacement yesterday and I’m the care-giver.
Next month I’m seeing a vascular surgeon to explore where this clot came from… I doubt I have varicose veins! Hopefully, I can discontinue the Eliquis and get back to normal riding.
Have any of the folks reading or at RBR had anything like this happen to them? I’d be interested to hear what others have to say.”
My Reply
I told Steve I was sorry to hear about his issue but really happy he’d found the issue and was on the track to recovery.
Steve’s Follow-up Email
“Yeah, it was probably a good thing that it was a small amount of lung involved. At least it seemed so to me. My O2 saturation got down to 87% at one point but got back up to normal within 24 hours. The hospital was thinking of keeping me another day, but I persuaded them to let me go since I had to be driving back home about 48 hours later. I wore compression socks on the way back, which we did even more slowly than on the way out. At least, once I was on the anticoagulant, I probably wasn’t going to get any more clots.
I made a post on Bike Forums and got a wide range of responses, from “no riding outside” to “screw it, I’m riding anyway!” My own position is somewhere in between, probably a bit closer to the cautious end. But I’m really hoping I get off the Eliquis; that’s really the only satisfactory outcome since my bike riding is a big part of my health maintenance program.
BTW, drugs that interfere with clotting are often referred to as “blood thinners.” This is a misnomer. There is no change in the viscosity of the blood; just a reduction in the ability to clot. Eliquis (apixaban) interferes with clotting by inactivating a protein. Other drugs (aspirin, for example) interfere with platelet aggregation. Both types have a similar outcome: reduction in the ability to form clots.
This is good for prevention of blood clots, but bad if you get a serious cut or have a brain hemorrhage. So even though I’m on an anticoagulant, I still have platelet aggregation as a sort of safety net. But I can’t take aspirin, ibuprofen, naproxen, or any of the anti-platelet drugs because then I just wouldn’t stop bleeding!”
I know there are doctors who read the RBR newsletter, and probably readers who have had pulmonary embolisms. I’d be interested to hear their points of view and how they dealt with this issue.”
Your Turn
There you have it readers. If you can help Steve, please comment with your ideas. Thank you!
Jim Langley is RBR’s Technical Editor. A pro mechanic & cycling writer for more than 40 years, he’s the author of Your Home Bicycle Workshop in the RBR eBookstore. Tune in to Jim’s popular YouTube channel for wheel building & bike repair how-to’s. Jim’s also known for his cycling streak that ended in February 2022 with a total of 10,269 consecutive daily rides (28 years, 1 month and 11 days of never missing a ride). Click to read Jim’s full bio.
There’s actually a bit more to this story than I told Jim (in the interest of brevity).
For probably the last 20 years I’ve taken an aspirin (“ASA”, 325mg) every other day for “prevention” purposes. Why not 81mg a day? No good reason, but I never had any problems with stomach issues. I would discontinue the aspitin a week before donating platelets, which I’ve done for years.
At my last annual physical, my internist pointed out that the recommendations for ASA for prevention of primary cardiac issues had changed. In my age bracket, the low-dose ASA is not recommended anymore. So I got a bit relaxed about it, and wasn’t taking it regularly. The day we left to drive to Boston, I remember looking at the bottle and thinking “Hmmm… should I take this?” and decided “Nah.” I’m wondering if that was a smart move.
I am 82, ride regularly on residential streets, solo, have been taking the 81mg aspirin up until about a month ago, now on Eliquis due to development of AFib. Cardiologists said to continue my exercise routine of riding and resistance training. Hoping to do a cardioversion soon and drop the Eliquis. I have had no bruising or bleeding. My friend on Eliquis said he is bruised all over and bleeding like he was in a cat fight. I told him to stop drinking alcohol, but he still drinks his homemade wine thinking it isn’t bad for him.
When I was 72, I thought I was in good shape, but I had a heart block/stroke walking home one night. I was diagnosed with afib and atrial flutter (aka “sick sinus syndrome”). The stroke was not diagnosed immediately because I had none of the usual deficits. Three days later, they checked and decided they were not capable if something worsened so I was helicoptered to another (larger) hospital where they implanted a pacemaker as a stop gap against the low hr. A few months later when I was able to get a referral and I put on eliquis. My PCP didn’t say it but I felt her attitude was that I should sit in a wheelchair in the closet for the rest of my life. The neurologist sternly warned that if I stopped the Eliquis I would die. Wonderful. I recovered with no major side effects and finally got to see the cardiologist. over the next 6-12 months I had two ablations, the first for the afib, and the second for remaining atrial flutter. A couple weeks ago I had a Watchman device implanted which will let me dump the Eliquis once the monitoring is good in a few months (just baby aspirin eventually). After the initial event, I had no symptoms (I never felt the afib, felt fine). I have been riding for the last year with no problem (I am head of a bike club in my community). You need to be an advocate for yourself. Listen but do not take as gospel what experts tell you. My annual tests came back with low iron (my crit has always been on the low side) and the PCP sent me to hematologist who sent me to a gastro guy who wanted to explore my gut for bleeding, but this would require stopping the Eliquis for 3 days. I presented the folly of this to my PCP – that the neurologist claims my death while the hematologist is saving me. Fortunately, iron pills have helped for this interim time. My experience is that there is a huge gap between the sit in bed and take eliquis forever approach, or reclaim your life. Fortunately my cardiologist intervened and we are holding off on the iron issue (nearly normal). I respect both, but I know what my choice is. I ride with a wrist bracelet re: pacemaker and Eliquis and take a bunch of clotting materials with me. I do not mountain bike (nor did I beforehand). Medicine in this regard seems stuck between “everything is a pill” (and the drug companies that seem to push it) and those that want to fix the problem. Good luck to you!
Hi Steve,
I have been on Eliquis for several years. My cardiologist put me on it because he knew I enjoyed riding and I’m very active too. My dose went from the 5 mg tablets to 2.5 mg a couple of years ago. I’ve had a-fib since 2008. My last ablation was successful, he still wants me on it. I get cuts and banged up from time to time and the Eliquis is not as bad as the some of the others I have taken. One of them made my blood drip like water. My cardiologist and primary care doctors tell me to enjoy myself. However, my case is not dealing with my lungs. You are very fortunate and will probably be more in tune with your body. Good luck with your recovery.
I think the choice is personal. With 4 ablations and 3 cardio versions and now 79, i choose to continue to play in traffic and ride the roads. I too am on a blood thinner and wear a med alert necklace. The choice is a quality of life issue to me. Fortunately, I do NOT live in Florida or other Meccas for the retired!
Thanks for the response. Yes, the decision *is* personal… that’s what makes it so difficult! The future is not completely predictable. As I would tell my patients when they would ask for an exact forecast, if I could see the future that clearly, I’d be working on Wall Street and making a heck of a lot more money!
My cardiologist put me on Eliquis AND baby aspirin after I exhibited some Afib while on a 2 week holter monitor. I bled and bruised easily while on that prescription. But…after a study showing the increased benefits from both Eliquis and aspirin were not worth the increased “benefits,” he took me off the aspirin. By comparison, I hardly bleed much at all should I accidently cut myself. I still ride in the Colorado hills without worry or symptoms. However, I did have a fall prior to the afib and the attending EMT’s DID NOT KNOW about my Road ID bracelet until I called their attention to it. Fortunately, I was alert and coherent. I’m afraid the Road ID may not be the security blanket we all hope it is. Another factor I’ve found is whether your doctor is an exerciser or not. 14 years ago, a 5 foot 6 inch, 250+ pound physician told my wife that she didn’t think continuing to play tennis was a good idea after an infection in her spine, which was completely cleared up. We still play 3 to 4 times each week, ages 71 and 75, and we are always the oldest on the court. Good luck.
Steve,
As a pharmacist and a cyclist and a practitioner working with anticoagulation for the past decade +, I tend to recommend a relaxed fear about the risks involved. Road/gravel riding will always have a risk of falls, and yes, if injury is incurred anywhere there will be increased bleeding / bruising due to the effects of an anticoagulant. However, your specific track record of falling reduces your risk tremendously, especially for a head bleed. This narrative would be far different if you were a regular mt biker.
The therapy for an unknown caused PE is 3 months anyway, so taking Eliquis for 90 days is really not that bad considering therapy for A Fib is lifelong anticoagulation (unless fixed surgically), and I know plenty of cyclists with a fib.
Why you got a PE could be a debate for the ages – long car ride, hard effort just before the car ride, random luck, etc. I highly, highly doubt it had anything to do with you skipping the morning aspirin.
Caveat – not having access to your complete medical history or being a cardiologist with vascular analysis, there’s a possibility of getting a PE for the general population; now that you have had one, your risk for a repeat does increase. So, do not stop the Eliquis prematurely so that your repeat risk is reduced as much as possible. Again, 90 days. And as your wife’s caregiver, she’ll appreciate the help with PT. If you do get out for a ride; ride like you always do – it doesn’t sound like you’re an irresponsible risk taker weaving in and out of traffic and bunny hopping curbs. Enjoy the fresh air, fitness, and a feeling of health amidst a frustrating diagnosis. Keep it very light intensity as the PE is healing, meaning there will be coagulation factors being released from the clot over the next few months.
Finally, thank you for clarifying the different mechanism of actions of those meds – very appreciated!
Thanks, Todd. I agree with the “relaxed fear” approach. Cycling has kept me in pretty good cardiovascular shape , and I would have *more* fear of what would happen if I discontinued riding.
For now, as a care-giver for my new-knee wife, I have to stick around the house. I was told I’d be on the apixaban for 4 months… I wonder if that’s the time-frame for the pulmonary infarct to resolve.
I’ll come back here and post the results of my visit with the vascular surgeon next month.
I was on Eliquis until last January when I had a procedure for a left atrial appendage occlusion device (Amulet or Watchman). This is supposed to minimize clotting effectively without the bleeding risk of Eliquis. I’m 81 and definitely not ready to hang up my wheels, although I did invest in an electric assist bike last year (for the many hills we have here in the Chicago Suburbs). Winter has me in my basement on a exercise bike.
I’m glad to hear you were able to get off the anticoagulant. I’m hoping for the same!
Which suburb are you in? I’m northwest of Chicago in the Libertyville area, and there are hills here. Northern Illinois is not as flat as some people think. I’m not ready for the e-bike option yet, but it’s good to know it’s available when I need it!
I live in Buffalo Grove. Not quite as hilly as Libertyville.
My ebike is assisted only if I’m pedaling. With its fat tires, upright posture and extra lbs I think it goes much like my old, light-weight road bike.
There are many senior athletes who have atrial fibrillation and are on long term anticoagulants. I have some friends in that category who continue to ride. I am an EM physician who has seen many head bleeds and many with bad outcomes. I personally would quit road biking if I had to take anticoagulants. I would probably switch to rowing, which is a great, low impact, low risk of trauma, nearly total body aerbic workout. I have a concept 2 rower in each of my homes and my wife uses them more than I do.
I ride about 150-200 miles per wk and do long distance bike endurance events. My frequent hill workout ride at a home where I spend 6 months/yr is a road that my riding friends never ride because it is “too dangerous”. So, I am not risk aversive. As we get older our balance gradually deteriorates as does our judgement. It only takes a brief moment of inattention to lead you a road hazard that will take you down. Even with a very good helmet that fall could be fatal or severely disabling to one on anticoagulants. Then there are the bike haters who fly by you very fast, hoping to scare you off “their” roads! A slight misjudgement on their part could lead to the same result.
If you like exercising outdoors as much as possible, you can learn to row or scull on the water.
As a retired surgeon I clearly understand your problem. Given it was a provoked clot, (ie due to the long car ride), your doctor will probably say that the eliquis will only need to be for 3-6 months. If so it means a lost season but you will be back outside on the bike soon. The risk of head injury is real and I would not ride outside on a blood thinner. I had a crash last December when I somersaulted over the rider in front of me who went down because he touched the wheel of the rider in front of him. Banged my head and tore my shoulder joint. I ride with a large group and this year I am one of 4 of us who had accidents of various causes, though usually involving a a car and. Careless driver. The risks of a crash if you’re on a blood thinner are not worth it. If I was on eliquis I would take up running or swimming.
By the way, though the data is not clear, I take an aspirin on long drives or flights over 2 hours.
Same thing happened to me when I was 50. I rode for a year on blood thinner (a bit more carefully than usual ).
Pulmonologist put me on folic acid, OTC. I’m 74 now. No problem.
Baby aspirin are no longer recommended so it probably wouldn’t have helped. Riding on anticoagulants is a personal decision. An experienced rider friend of mine had a minor spill not on the road but at the end of a ride in a parking lot. He felt fine but that night he never woke up because of a brain bleed. On the other hand lots of people continue to ride on anticoagulants. Weighing risk vs benefit is what cycling is all about. You have to decide if it’s worth the risk.
I asked my cardiologist about the aspirin recommendation and after she consulted the cardiologist who did my alcohol septal ablation, the decision was that as active as I am that I should continue taking aspirin. I ride and do resistance training and I am 82. Currently I have developed AFib, so no aspirin but have to take Eliquis. Plans are to do a cardioversion soon and drop the Eliquis.
I haven’t had the physical issue, but for sure it’s a matter of how much risk you personally would take. There’s one work around for awhile: use an indoor trainer and one of the amazing programs (a la zwift) for awhile. See if that gives you adequate thrill 🙂 or at least use it until weaned off the meds.
First, some medical info: varicose veins do not cause blood clots to the lungs, pulmonary emboli are caused due to clots in the deep venous system, which, when sitting for prolonged periods, have partially impeded return of blood to the heart and it is the slowed blood return to the heart in those vessels that increases risk of clot formation. There are other medical conditions that increase the risk of clot formation that also need to be investigated by an internist or hematologist.
Now, about bike riding…I’ve been riding for decades and I must admit a skilled rider understands “risky” areas, like loose gravel or tight turns taken too fast, etc. However, the decision to ride, is one of a rider’s “risk appetite”. Everyday we take risks, (i.e. stepping out of a shower with wet feet on a tile floor, or just driving to a local destination), so we take risks everyday without necessarily thinking about them. So the first question is what’s your risk appetite?
The decision to ride also has to do with the level of safety of where you ride and the condition of the roadbed you ride on, coupled with the weather (wet or icy roads, gravel bed vs asphalt or concrete, on road or off road trails/bike paths, competing auto and truck drivers sharing the road with the bike rider).
Being on a blood thinner due to a pulmonary embolus will, without question, significantly amplify the risk of spontaneous and post traumatic bleeding, which can result in anything from a bruise to a life-threatening hemorrhage. So to sum up whether to ride, Dirty Harry said it best….”Do you feel lucky?”
After road biking regularly for 25 years, to my great surprise I had a coronary stent procedure at age 50 (which I wrote about in RBR). My cardiologist prescribed an anticoagulant, which was awful for my active lifestyle. I continued to road bike, and had one spill that took off some skin left me with blood running from my wrist down my forearm and dripping off my elbow. It looked gruesome by the time I got home 15 miles later. After a couple of years I got my cardiologist to reluctantly agree to let me continue an 81mg aspirin a day and drop the anticoagulant. I’m now 66, still riding, and have had stellar checkups with my cardiologist every year.
This is just one data point, but I rode while taking an anticoagulant with my cardiologist’s blessing. It was bad for the two years I did it, I’m glad I got to change that part of my medical regimen. For my doctor and me, the benefits of continuing to ride outweighed the risks. Maybe you and your doctor can work out a compromise now and a better compromise in a few years.
By the way, a year after my stent procedure I was hit by a truck while riding. Because I was on an anticoagulant, several extra diagnostics were performed in the ER. Fortunately, I was negative for a brain bleed and had only minor internal bleeding that quickly resolved. I understand your doctor’s concerns. At the same time, I will say that I was only off the bike for five months after my accident, enough time to heal from my injuries and the first of three surgeries I had post-accident.
It’s all a long story, but back in 2003-2004 I had a coronary stent placement and a triple-bypass of my left main artery. After the stent, my cardiologist placed me on 325 mg aspirin daily, which I take to this day. My stomach handles it just fine. I have noticed that skin cuts take a bit longer to clot up – maybe 10 minutes instead of 5 – but nothing serious. I have never been concerned about internal bleeding, nor have any of my doctors (internist, cardiologist, gastroenterologist) mentioned any concerns. Maybe that lack of concern is pure ignorance on my part – I never thought much about it until I saw your letter. I will be 70 in January and I run, bike, and ski regularly. My take is any internal bleeding or brain bleed that’s serious enough to be a problem would be a problem with or without aspirin or Eliquis. But I’m no doctor, just experienced at taking aspirin and getting injured….
Side note; This all started with chest pain while running. I first realized I had a serious problem when I w
90 days. Instead of a sacrifice, use it as an opportunity. Explore the varied online worlds. Strength train, improve your FTP- whatever you have always intended to do, now is your time to do it.
Exercise lowers risk of heart attack by fifty percent at levels of exercise barely above that of “thinking about it really hard”. Also cancer and overall dying. There’s other benefits.
https://nypost.com/2024/09/04/lifestyle/doctor-reveals-the-disgustingly-small-amount-of-exercise-someone-needs-each-day-to-help-slashes-the-risk-of-cancer/
This is sorta linear of exercise/benefit relationship up to about gym rat level of exercise where it levels off a bit.
I believe the risk of fatal autoaccident risk is roughly 1 in a million rides and what? ten times higher than that for serious non-fatal accident?
Ask the doctor if he’s done the model for expected years of life for bike and exercise versus bleed. The doctor will reply “there’s many forms of exercise” or something less intelligent. Calmly say, “well, if they didn’t teach you mathematical modeling, which of course is the basis for all science and all factual knowledge, I guess I will leave you to your bone fetishes, astrology, and leeches”.
Look up hirudin if you think this isn’t a serious statement.
I’m a primary care doc. I just give my best estimate of the numbers for the patient to make their own choices (as I pointedly put on my biking helmet).
Many good replies thus far. Let me add an unique experience I had when I got off my indoor cycle and felt a soreness in my lower leg. At first I thought a sore calf muscle from too vigourous a workout. After repeat indoor rides the soreness changed to a rope like swelling of my left lower leg with associated redness Local PCP diagnosed a superficial venous thrombosis and recommended conservative tx including RICE (rest ice compression and elevation) and baby aspirin. At my then tender age of 68 I thought this initial diagnosis and treatment regimen not good enough to explain this unusual event to an otherwise active cycling person. Hematology consult after many labs and more intense history and physical assessment revealed an autoimmune disorder wherin the blood clots without any external causation. I was diagnosed with APS (antipospholipid syndrome). My age and gender made this a highly unlikely diagnosis at first glance; nevertheless, I did apparently inherit this genetic anomaly from my mother who had many miscarriages during the 1940s..
Now, at the less tender age of 80 I still ride on the roads of my local retirement community but I do not travel on any other roadways – way too many distracted drivers. I am on lifelong warfarin and have had some challenges maintaining a normal bleeding risk since I also was found to have a peculiar genetic sensitivity (VKORC1) to warfarin – a very little bit goes a long way. The indoor cycle remains my best friend from a maximum safety profile.
The final lesson I have had to learn is that risk assessments are sometimes naive hope that all will be well just becasue one is now aware of newly discovered changes and threats. The lesson of aging is that new unannounced threats are always lurking in the background. Although I think I can wrestle with the newly discovered risks I know with more certainty of passing years that nature will have the last say, and I am not always going to be informed beforehand.
It is worth the time to get a good handle on the cause. In our area, Eliquis for 6 months regardless of cause and you can go off after 6 months if you know the cause and remove it. Causes may include sedentary positions (flying, long car rides with DVT, etc., presence of cancer in the body, coagulation issues, hormonal issues in women, and sadly Covid or other virus exposures. A good follow-up with cardiologist is necessary to ensure no long-term effects of trying to pump blood against the extra resistance of the clots. I am four months into my 6-month journey and have elected not to ride outdoors while on Eliquis. Mine appears to be Covid related, and I have taken to Zwift and indoor training to get my training in. It is a personal decision, but giving up 6 months in the off season seemed like a no brainer to me.
I had a PE in 2005 as as result of a
DVT in my right calf. After some extensive testing, no particular cause of the clot was determined and I was prescribed a 6
Month course of Warfarin as a preventive . During the Warfarin treatment I did stop cycling (but it was during the winter and early spring so lost bike time was minimal). After Warfarin I started taking one adult size aspirin a day. I had recurring clots (but no PE) in 2011, 2014 and 2016, at which time the vascular surgeon recommended a move to Eliquis (5mgs, 2x per day). Since then, no more clots and I’m still riding 4k-plus per year. I’m going to be on Eliquis for the rest of my life (I’m 71) but the overall impacts on my health – other than the elimination of DVT – is basically nil. I had a bike crash earlier this year and bleeding from the road rash wasn’t any more than I would have expected before I had these issues and
Medication.
Steve –
Having gone through two separate occurrences of bilateral pulmonary embolisms, I understand your concerns and questions. These events happened 16 months apart and took place about ten years ago. The first event led to a seven-day intensive care unit stay with Heparin therapy, while the second resulted in just an overnight hospital stay and five days of self-administered Lovenox injections at home. Following the second episode, my family doctor prescribed an anticoagulant (Xarelto) for “life.”. He stressed that my “life” would likely be extended by taking it for “life.”. I take a 20mg Xarelto tablet daily without any adverse effects.
My collaboration with a sports medicine pulmonologist following my second bout illuminated several points:
1. Athletes may experience clotting issues because they tend to have thicker blood (due to an increased production of red blood cells to transport more oxygen), they usually have lower pulse rates (as their cardiovascular system is highly efficient), and they often fail to hydrate sufficiently (which further thickens the blood). The formula he presented was clear: thicker blood + slower heart rate + inadequate hydration = higher clotting risk.
2. Clotting-related deaths among athletes are not uncommon and are frequently misidentified as strokes or heart attacks as a result of clots.
3. He encouraged my continued riding while stressing the necessity of adhering to certain safety measures:: always wear a helmet, carry identification or a wristband that indicates my use of anticoagulants for emergency medical technicians, have a cellphone readily available, inform my cycling partners of my medication, and be aware that the risk of injury increases with certain styles of riding.
I dont know the pharmacodynamic half life of eliquis but one risk optimising idea would be to ride before you dose ie ride at max time since last dose (without hugely departing from the 24h gap between doses…or whatever is your ideal dose interval). Worst case…there is a reversal agent for Eliquis that is conditionally FDA approved for life-threatening bleeding and might be available and appropriate in some circumstances especially if your thrombotic risk is low compared to the average eliquis user.
I had a similar PE event in my late 60’s. I rode 5 days a week through 6 months of Eliquis. My doctor warned me to be aware of slow clotting, but never suggested a change in my routine.
Wow! Thanks everyone for all the replies to Steve!
Very much appreciated,
Jim
I’m 84, have had afib for 10 years, first controlled (normal rhythm) for a few years with drugs, then for three years with an ablation, then for some years with the ablation and drugs. Multiple cardioversions along the way. I took Pradaxa when in afib but not when I was in normal rhythm. My cardiologist suggested Pradaxa because it has an antidote that I can take (be given) if I have internal bleeding. I have no idea if there is a antidote for Eliquis. At this time I’m in persistent afib, I had a maze procedure to try to control the afib at 81 but it didn’t cure it; however, my heart rate is in an acceptable range both resting and exercising so I don’t take any rate or rhythm control drugs, just the Pradaxa. One part of the maze procedure was to clamp off the atrial appendage, the same area the Watchman occludes. In theory I could stop the Pradaxa but my cardiologist has take the cautious route and suggested I keep taking it, which I have. I had a bad crash at the beginning of 2024, broke my elbow and tore lots of skin off both arms. My external bleeding seemed to be no worse than without the Pradaxa, though my arms were a bit of a mess. I didn’t have any internal impact, head or body, so no chance of internal bleeding. I still ride and am not in any way concerned about riding with the anti-coagulant. We accept many risks riding bikes; I don’t feel that riding while taking Pradaxa is adding much risk to this already risky sport.
After a mini-stroke, I was prescribed a baby aspirin daily. On reading the book called ‘how not to age’ by Dr Gregor, I replaced the aspirin with a tspoon of cumin daily for the same effect but more naturally. I am 84, fortunately with a healthy heart. I resistance train to failure plus regular cycling on the road.
Maybe this is of some help.
Pete.
Although taking 81mg aspirin, I had a massive PE in 2013 with 7 days in the ICU, but was cleared to go off Eliquis after 3 months. I resumed riding (about 7000 miles a year). Then I had another PE in 2021 and went on Eliquis “for life” and was told to never crash. I switched to Zwift and actually love it. I’m late 60s now and I’m racing regularly, which I had never done IRL. It kind of changed my perspective: no hazards or crashes, no wind/bad weather, made new international friends, a different kind of fun. It was a bit of a paradigm shift when I think about the risks I took riding outside solo and in fast groups. I get my outdoor fix hiking with the pup; and I still ride outside occasionally, including a few bigger trips like a week in Colorado and Mallorca. You could ask to be tested for ‘factor V Leiden’, a marker for risky clotting.
I’m 65, riding for over 50 years, and in great shape. No medications. I’d suggest to anyone, get your DNA checked at The DNA Company. Why? After a heart attack 10 years ago, and a stroke this year, January, 2024, and recovering from both immediately, and excellently, I wondered how a healthy individual could experience this. I cycle an average of 2 to 300 miles a week. This past June, I did nearly 74 miles a day, every day, for over 2200 miles for the month. My DNA results came back this past October, and I found out that I am estrogen dominant, meaning I should be doing more muscle work than cardiovascular. I also have poor quality endothelial cells lining my arteries and veins. My report says I should be doing 45 minutes of low rep, high weight circuits, and resting a day in between. I also found out that I should be restricting my cardio workouts to 45 minutes twice a week, and not exceeding 60% of max heart rate, due to my inefficient artery walls! This has thrown me for a loop, and explains the reason for the heart attack and stroke. So, for anyone having any unexplained problem, PLEASE get your DNA tested. You will learn unbelieveable information, and be able to understand your problems, and possibly PREVENT future problems, by understanding how to improve your future health with natural, nutrional compounds. Best of health to you all!
Thanks, everyone! I’m having technical issues getting responses posted.
I’ll hopefully be able to respond soon. Meanwhile, I am trying to get thanksgiving dinner out for my wife, who is 7 days post total knee replacement.
Steve
If there was no underlying cause for the PE (ie, no coagulopathy), and the PE was not massive or submassive (ie, small), then hang in there on the trainer til spring, get off the anticoagulant, and hit the road.
There’s a lot of information here. Many thanks for taking the time (on a holiday!) to respond.
Clearly, there’s not one single answer to my question. Here’s my plan:
I’ll do any riding on my inside trainer until I see my vascular surgeon. If they want me to complete the 4-month course of apixaban without outside riding, I’ll comply. Since my clot seems to have been from a “preventable” cause, I should be able to resume normal riding. Then I’ll take extra precautions on long drives and flights: compression socks, frequent position changes and maybe aspirin.
If I have to stay on Eliquis, I’ll ride carefully. Well, I am a fairly careful rider; I don’t suck wheels and my average speed on the road is probably 15MPH. I always wear a helmet, and I have the “Road ID” tag and a watch that recognizes a crash and can call for help. I can also stick mainly to off-road trails, which are prepared, crushed-stone, not single-track. While I appreciate the suggestion for other kinds of indoor exercise, those (including cycling) really don’t satisfy me. I love being out-of-doors where I can see scenery, hear wind and wildlife and actually get somewhere.
I am keeping all my appendages crossed that I get released from the drug! I’ll come back and report what I find out next month. Meanwhile… I’ve got a bike to assemble, and some other maintenance to do. Cheers!
My 2 cents: I’ve had 2 PE occurrances, both with similar focused pain in the lungs. I chose to use warfarin because it has an antidote. I ride indoors and out 5000 + miles a year. Warfarin is kind of a pain because you have to test regularly, I chose it knowing my chances of crashing were above average and that Vitamin K reverses the effect. Just went through an internal bleed issue that was resolved in hospital with Vit K injection. At 78 years old happy with my choice. RIDE ON.
FWIW, they have antidotes for Eliquis now.
Have you seen how much Andexanet cost? 😯
https://pmc.ncbi.nlm.nih.gov/articles/PMC6705484/
It makes the $500 deductible that I pay sound trivial!
Guess, I have heard that. Warfarin costs me $10 a month. Elequis? $400?
Luckily, I only had a $80 co-pay for a 4 months’ supply of Eliquis. Warfarin has requirements for blood tests to monitor its effectiveness; the “Direct Oral Anti-Coagulants” (like Eliquis) don’t have these. That still probably doesn’t bring them to parity, cost-wise.
Try Canada for the blood thinners
I am a retired physician (Internist/Gastroenterologist) and have treated many patients who are on blood thinners for various reasons, including PE. I am also an avid cyclist. I typically log 150-175 miles weekly with other members of a local bike club. I have seen many fellow cyclists go down and break bones, suffer concussions, suffer internal injuries like ruptured spleen or pneumothorax from broken ribs. Most of the people I know who were injured were experienced and cautious cyclists, who had an accident despite their caution. Because of my experience, if I was taking any blood thinner, I would not cycle until I finished the treatment. A seemingly minor injury could have devastating consequences due to the increased bleeding risk. Examples would be a brain bleed, a hemopericardium (bleeding into the sac around the heart), or a ruptured spleen. I would take no comfort in a prior accident-free history. Most physicians are not aware of the risks of cycling. In my experience, anyone who cycles long enough will probably have a significant injury at some point. I would use a trainer.
I had my follow-up with the cardiology/vascular medicine doctor a couple days ago.
He believes my embolism was of the “provoked” variety, and after some more tests if there are no significant findings indicating otherwise, he will take me off the anticoagulant. Going forward, in any case he feels that some form of low-level anticoagulation may be desirable for long car or airplane rides, any orthopedic surgery or hospitalizations
The tests pending are:
Chest CT scan to evaluate the resolution of the clot,
Echocardiogram to assess right-side heart function,
Ultrasound studies of the legs, and
Genetic testing to see if there is any tendency toward hypercoagulability.
He supports the recommendation to stay off the bike outside.
He also said he thinks I probably wouldn’t have had this problem if I had taken the aspirin, but it’s impossible to say. I have another visit to see him in March.
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Thanks, Kevin,
First I’m going to see what my regular healthcare channels find out. It’s good to have an alternative though!
Steve –
Here are three articles that were shared with me by my pulmonologist after my second bout with bilateral pulmonary emboli. First bout was bad, second bout (18 months later) was much worse. Am now taking 20 mg Xarelto for “life.” Take a look.
https://www.trainingpeaks.com/blog/athletes-and-blood-clots-know-your-risks/
https://www.stevelehmantours.com/2013/08/blood-clots-and-the-endurance-athlete/
https://pubmed.ncbi.nlm.nih.gov/28301715/