Atrial Fibrillation: NOACs, Warfarin and Vitamin K Antagonist

Controlling risk factors like Hypertension, Diabetes, Dyslipidemia and obesity helps prevent Atrial Fibrillation
Dr. Mohan Nair

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Dr.Kunal Jhaveri

Today we have one of the leading interventional cardiologist doctor and professor Mohan Nair who is currently the coordinator and head of the Department of Cardiology from Holy Family Hospital based at Delhi. Sir, it is warm welcome for revolution talk. Sir, as you know regarding the arrhythmic disorder the atrial fibrillation we can say it is a commonest arrhythmic disorder wherein the incident rate is of around 30 to 33%. But still there is a debate on whether this incidence rate globally which is around 1.8 to 2%, whether it is a actual one or it may be a fact number, so what is your take on this particular aspect.

Dr. Mohan Nair

See actually, we did look at this and coming and also because of atrial fibrillation treatment was getting changed when I was of President of Indian Heart Rhythm Society about two years back, we did very reasonably large (01:00) longitudinal study, most of the studies have been vertical so far, and that study showed that it included both private hospitals and public hospitals, rural and urban population and just taking patients on point of care, we then followed them up. The followup was about one year, 98% followup could be out in one of journal soon, and we are surprised to find that we have a double problem. We have age-related atrial fibrillation which is the same as in the west and surprisingly although we have seen less of new rheumatic fever patients but patients with old rheumatic heart disease consisted close to 50% of the IHRS atrial fibrillation history even now, which means we have as many patients as the west plus a huge population of atrial fibrillation due to valvular heart disease still which is a little alarming and we need to now work on how to be proactive in that. It is surprising for us also because we thought that (02:00) rheumatic fever is coming down so we will have more age-related and not the rheumatic fever related atrial fibrillation but it is 49.8% of rheumatic atrial fibrillation and that it is very well conducted Indian Heart Rhythm Society registry which I initiated when I was a president and now the followup is there and the data is very very strong.

Dr.Kunal Jhaveri

So definitely it is very well said that in India because the rheumatic condition is so widely prevalent, number of the valvular AF cases are much more as compared to the non-valvular cases.

Dr. Mohan Nair

It is equal now, it is almost equal.

Dr.Kunal Jhaveri

Now it is getting more equal. There is also one concept regarding the screening of atrial fibrillation going on, that how we can, means, that a clear and on time diagnosis of atrial fibrillation and we go ahead. So which kind of risk factors, if the patient is having these kind of risk factors, then you will focus more that this patient should have screening for the atrial fibrillation.

Dr. Mohan Nair

See a lot of patients (03:00) screen because they have some symptoms of palpitations, dyspnea, arrhythmia. Honestly, I do not think we are screening all hypertensives for atrial fibrillation, but what has been very, even right often I talk at the CSI, I was emphasizing on the I give to atrial fibrillation and stuff. I emphasize and it is amazing how people are trying to do it. Any patient who has had a CVA or TIA now at least in our hospital and a lot of other hospitals it is a protocol that there would be at even cryptogenic CVA and we started doing Holters, then I see how many of silent atrial fibrillation are picked up. So that is one area where I think that we have done a lot of progress. At least 30% of this so called idiopathic or cryptogenic CVA or TIA turn out to be atrial fibrillation and then there is a huge hope with the new oral anticoagulants and the anticoagulation to prevent the next stroke, but if you say cryptogenic or another cause, so we are just leaving the patient on whatever it is. So that is where screening started. The rest, may be (04:00) there will be a time when we honestly of course both ablation patients and population studies have shown that risk factor production play a huge role in decreasing the incidence of atrial fibrillation. So that it is known from, there was a time when it was you know, some studies said yes, some studies said no, but now it is very clear that treating hypertension, dyslipidemia and other coronary risk factors, diabetes, overweight, etc, if you meticulously treat, you do not have as much atrial fibrillation as similar population which has not been treated and also patients who had ablations for atrial fibrillation, the focus is even by electrophysiologist on risk factor reduction so that they do not have to ablate again.

Dr.Kunal Jhaveri

Yes, perfect there. Regarding for the control of atrial fibrillation the surgical intervention is also now happening and the rate and rhythm control, some ablation kind of procedures are also now very prevalent (05:00), but if you talk about the prevention of complication in active physician, the stroke is a number one priority and I think four to five times high-risk of stroke and regarding the stroke prevention in atrial fibrillation the number of the treatment has been so available from the vitamin K antagonist, then aspirin and now newer generation also as well. So, in your practice definitely you must have passed with all oral anticoagulants, so how do you find these kind of changes and up to what level this changes are welcome.

Dr. Mohan Nair

See as far as I do of course get filtered patients on what I say my practice may not reflect the general practice but that will reflect over a period of time. As far as evidence goes, it is very clear that unless you have a CHADS2 score of 0 or 1, aspirin has no role, nor does aspirin from clopidogrel, that is last choice, only if no anticoagulation can be used. Two and above you have to have rigorous anticoagulation (06:00) being given and when we did the survey, I started with a physician then there was an Indian survey, then the society did a survey and it was amazing that Indian physicians were most aware regarding the new oral anticoagulants but they used anticoagulation the least. Perhaps one of the reason was the risk of bleeding, because if a patient has an atrial fibrillation that is his disease. If the patient has bleeding on anticoagulation that is your. So there was this problem, but I think that is where the new oral anticoagulants come in, because we have patients who are from remote places. You have honestly not very great random standardized INR rates, most of the dos and don’ts regarding food and drugs, drugs are same but the food that, if you look at the food list, it is the western food, you do not even know what palak does, you know, all those Indian food, and also in medicine we do not know what the Indian system of medicines, herbal medicines that (07:00) they take, ayurveda, homeopathy, how they react with this Warfarin. So we used to have whole lot of problems with INR going here and there and to be honest at least my patients are very happy when I tell them that now we have drugs where you do not have to be worried about eating at a wedding for example, they go for a wedding, they do not know what they have eaten and next day the INR is high, they come to hospital, I have had doctors coming to hospital with a bleed. So that is a big relief. The only thing, I think the awareness needs to go out more and it will occur, it is a matter of time, most of my new patients with atrial fibrillation, the new oral anticoagulants are offered as upfront. The problem is patients on Warfarin, if they are having labile INRs then it is easy to convince them, but if they have been having for years, they are happy with the vitamin K anticoagulants, then you need to discuss because I do not know whether these patients should be then taken (08:00) off vitamin K and new oral anticoagulants should be given. So that is the only segment where I do not touch too much but all new patients are offered and also patients who are having problems with vitamin K antagonists are on new oral anticoagulants.

Dr.Kunal Jhaveri

Definitely, this is a very practical point that you have raised that vitamin K antagonists have this type of limitation and new oral anticoagulants can resolve all these limitations regarding the INR monitoring and better compliance. Now this is last question. Regarding the new oral anticoagulants, as of now three new oral anticoagulants are available in India, factor X inhibitors and direct thrombin inhibitor. So in your experience how you have found that this drug should be given for such kind of patients. How you choose the new oral anticoagulants for treating this.

Dr. Mohan Nair

See honestly the first staff meeting with the new oral anticoagulants was in Brussels in Belgium and I was there from that time onwards. So in India, honestly dabigatran has the first more advantage. So this was the International swab, (09:00) then we had the Asia Pacific swab, the Indian swab meetings, most of them were revolving for about two years with dabigatran. Now we have all the three. One, very sure, that in terms of prevention of thrombotic stroke and prevention of positivity it is just 150 mg b.i.d. of dabigatran which has shown superiority. All the others are non-inferior. But bleeding is least of Apixaban, rivaroxaban and then dabigatran, that way. So if I have a patient who has got a high CHADS2 score and a low HAS-BLED score then perhaps the dabigatran and rivaroxaban or apixaban can be suggested. Some patients do want a single dose where the rivaroxaban has an advantage. On the other hand, if you are having a patient who has HAS-BLED which was nearing 3, beyond 3 of course you are very much concerned, low CHADS2 score (10:00) between 2 and 3 or up to 4 and HAS-BLED which is 2 or going to 3, in that case of course I go increasingly towards the rivaroxaban and apixaban and that is what simple to put it. Then of course if a patient has gastric irritation then I cannot give dabigatran because the dabigatran gives gastritis which is worse than the worse gastritis you can see. The same way none of these can be used for people who have renal dysfunction and of course valvular A. Fib, it will be a question mark with the real line study actually I think that was an unfortunate study. So that is the way you have to invidualize and you have now choice of all the there and you look at what the patient is. I do not think one drug fits all situation, so we need to read and tell other people who are using also and say that all three have their advantages and disadvantages (11:00) and put it on the chart and see.

Dr.Kunal Jhaveri

Definitely, it is a very practical thing that you have mentioned regarding this, as of now there is no clear cut comparison between.

Dr. Mohan Nair

There will not be. I do not think there will be.

Dr.Kunal Jhaveri

Definitely or even in far

Dr. Mohan Nair

We have event of registries and post marketing service but otherwise you do not have a

Dr.Kunal Jhaveri

So that is what, one new oral anticoagulant will not be fit for all kinds of patient, you have to be customize and based on the patient’s requirement and risk factor and conditions you have to choose that.

Dr. Mohan Nair

Absolutely.

Dr.Kunal Jhaveri

So with this note, we are ending our discussion. Thanks a lot doctor for providing us your valuable thoughts.

Dr. Mohan Nair

Thanks.