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So sir if we talk about especially the prevention part of cardiovascular segment. So now a days there is a concept that the prevention is always better than cure and now it is very aggressive that from a physician prospective as well as from the different kind of pharmaceutical companies are also promoting this kind of the prevention concept. So regarding this prevention of cardiovascular disease what is your opinion on this particular segment sir.
If you seen in Cardiology, if you see the way acute anterior myocardial infarctions have changed. If you see over the last 30 years the acute anterior myocardial infarction numbers have plummeted in the west. In India and China it is increasing, but even over a period of 10 years we expect these numbers to plummet. So in terms of cardiovascular disease, acute myocardial infarction and chronic stable angina all these diseases are going to plummet. If there are any two segments which is going to grow over the next decade or so, is two conditions, one is atrial fibrillation (1:00) another is heart failure. These are the two epidemics I would say of the next generation or next decade or so. So these are the only two conditions, if you analyze the American data you will clearly realize that there are only two epidemics which are growing and that is atrial fibrillation and heart failure. Part of it is due to the aging of the population and part of it is due to the fact that people are surviving longer. So people do not die of MI immediately. They survive, then they develop heart failure over a period of time and that leads to a whole set of conditions. So if we were to look at prevention in Cardiology, the future of prevention revolves around these two scenarios, that is atrial fibrillation and heart failure. Because with respect to coronary artery disease, I am not saying we have reached the peak in India, but at least world wide we have reached close to the zenith. We have reached a point where whatever maximum could be done in an acute myocardial infarction is already being done. So we are already meting the so called goals or you know get to the guidelines concepts and we are already reaching targets. (2:00) These are two areas where we need to do something that is atrial fibrillation and heart failure.
So it is very well said the atrial fibrillation and chronic heart failure both are now it is next era what we can say, last era what we can say was cardiovascular disorders, metabolic disorders like diabetes, but now the recent researches and even guidelines are also focusing on these two conditions regarding atrial fibrillation and heart failure. Now if we talk about the atrial fibrillation and its prevention, global incidence rate if we are talking it is about 1.8 to 2%. So it seems to be under detected and that is why definitely even all the governments are also now proposing this kind of awareness regarding atrial fibrillation. So what is your opinion on this particularly disease, that how can we increase the more and more incidence of it.
See this whole concept of incidence is very frivolous. You know when you are in school you are taught one proverb (3:00) the eye only sees what the mind knows. So very often many physicians also see patients with atrial fibrillation, they do not recognize. So forget about knowing the incidence in the general population, even in patients coming into the hospital, patients walking into a clinic when they go to a routine ECG and find an atrial fibrillation, hardly anybody detects it. So forget about knowing the prevalence in the community, even in people who come to the hospital which you know is a high risk itself, even in that subset when you are not picking up things, forget about, all these numbers are I personally feel wrong. The reason is we do not have a very systematic way to evaluate. In fact, see I have been into practice for the last 10 years. So in 10 years I have seen AF I feel as if I have been practicing Cardiology for 40 years. That means as per prevalence, we are missing out almost like four times. So we have seen so much of AF, so it is very wrong (4:00) to you know generate data from west and say that you know our prevalence is low. I do not believe it. We do not see. Ultimately, coming back to my staring statement if you do not know, if your mind does not know, if you do not have the keenness to lookout for atrial fibrillation. I will put in a simple question, you go and ask 100 neurologists today and ask them how many people you have consciously looked at AF as a probable etiology of a stroke and I can assure you out of 100 neurologists more than 80 to 90% will say we never thought of it. Some of them would have referred to a cardiologist, the worst part is after being referred to a cardiologist also, a cardiologist also 50% of the time would have done at transthoracic echo, done a transesophageal echo and stopped at that level. You will never find a cardiologist in any center looking prospectively at every patient who has had a stroke to rule out whether (5:00) there is a possibility of underlying atrial fibrillation which itself says the true story. See forget about general population, people visiting the hospital and people presenting with stroke, even in them we are not aggressively looking for AF. So how can you say the incidence of atrial fibrillation is low. The fact is that we are not looking at it. That is the sad truth.
So whatever number is there actually is not the actual number.
It is just like this. I will put it in simple words. If I open my eyes at 10 o’clock in the morning and says sun rises in the morning, it is something like that.
That is very well said. If we talk regarding atrial fibrillation and its complication, the stroke is one of the major complication when there is atrial fibrillation. You also said that when the stroke is happening then you have to go the retrospective to find out the underlying causes of atrial fibrillation. But now even the data is also saying that even when the patient is diagnosed with atrial fibrillation, there is no aggression is also seen in the physicians level to treat the patient (6:00) for prevention of stroke. So what is your experience on this particular concern as well.
The thing is very simple. At any point of time, any therapy, there are three issues involved. One is called the cost benefit ratio, second is called the risk benefit ratio, and the final thing is cost-risk benefit. So when it comes to atrial fibrillation, the biggest challenge faced by a physician is when you tell the patient that the risk of bleeding or the risk of treatment is almost parallel to the risk of benefit. When you put people on a warfarin therapy or things like that tell me how many patients would be convinced. Forget about the cost, cost comes later into the equation. You start off telling the patients that you have a problem, I will give you a treatment, this treatment may prevent the problem but may create another problem and may not still prevent the problem. If you make such a statement tell me (7:00) out of 100 patients how many will willingly take treatment. You know that is the problem. See when you put the whole thing in a picture holistic way, you look at the patient, you talk to them, you tell all the risks, you tell all the benefits, then itself it becomes a challenge. Now on top of it put the burden of cost, then technically you have ruled out any therapy and somehow down the line I have seen how patients are treated in US versus the people are treated in India. Somehow in India our treatment is reactive. That is we prefer to do something only after something happens to us or in your language we would call it as secondary prevention, but in US the concept is of primary prevention. So in India it is very, very difficult even for doctors to understand the philosophy of primary prevention. So forget about patients. If doctors cannot be convinced about primary prevention (8:00) and there are so many hurdles in secondary prevention that primary prevention looks like you know utopian dream king of thing.
That is definitely, it is the real world kind of scenario is of now in India as well. So if we talk about the management part of a stroke, definitely primary prevention as well as secondary prevention, various anti-thrombotics are available since aspirin, warfarin now the newer generation has also raised out. So you have passed with all the phase of these all three drugs. What you have found the advantage and also the challenges with older versus newer generation.
See if you forget about NOACs, if you discuss Pharmacology in general, like this has lot of analogy to the gliptins in the market also. 25 years back when I joined medical college the concept was for more powerful and powerful drugs.
Okay, so if tablet A is having this much effect and tablet B is having double the effect (9:00) immediately tablet A goes out of the market because you have a drug which is tablet B. Gliptins and NOACs are the two classical examples of newer drugs, where we are not talking about efficacy, we are talking about safety. So we have come to a scenario where we have started telling people that this drug is less effective but more safe and this concept not only sells today, is the flavored theme of doctors today. So we do not want more and more powerful drugs which were there 25 years back. You know as a medical student I used to think that more and more powerful drugs, but today I am looking at not more and more powerful, I am looking at drugs which I appreciate will be less powerful. I appreciate will not be not as effective as the other drug. But if you assure me that it is going to be more safe then I am ready to take it. The gliptins are proof of it. You know it is like thousand crore brand in India. The reason everybody in the field of diabetology knows that gliptins are the weakest (10:00) new drugs to hit the market. But they are growing simply because they have promised us safety. So same applies to NOACs. Now you put the ball in NOACs court. NOACs have never been proven to be superior to warfarin, but the beauty with them is they are offering us the benefits of safety, of compliance, side effect, drug interaction, all these things. Not a single NOAC has won the argument of efficacy, but almost all NOACs across the board have won the argument of safety to an extent. May be some of the drugs have failed in their safety test also, but in general most of the NOACs have won that argument and that is why today NOACs are so popular.
So definitely the newer generation oral anticoagulants they have some advantages as compared to the challenges of the vitamin K antagonists. Now if we go deep inside to the NOACs part, as of now in India the rivaroxaban, dabigatran and Apixaban, these three drugs are available. So how you will customize your patient according to the drug (11:00) means how you will use this drug in various kinds of patients. Suppose this drug has no any head to head trial, no comparative data individually, means with each other. So how will you select that this drug can be used in this patient and this drug can be used this group.
See I know I should not compare this to real life, but in real life also very often we have a concept called as first come first sell basis.
Okay, so if you go back to our experience with NOACs, the experience with NOACs is almost like five to six years now. So, obviously since dabigatran was the first drug to be launched. So we had huge experience with the dabigatran like I can confidently say that more than 400 to 500 patients of mine are on dabigatran, so that is a huge number when you compare with other NOACs. So definitely dabigatran has a huge lead over all the drugs simply because they are first to hit the market.
So that advantage with the dabigatran will persist at least for the next five to six years if I am not wrong. (12:00) So that lead will always be there that dabigatran was the first to be introduced, the first to show safety, the first to show efficacy and if you look at dabigatran data with 150 mg that is a very robust data looking at efficacy over warfarin. Till date you have never had any NOACs showing superiority over warfarin in any track. So dabigatran for that matter has been very specific in showing a slight superiority over warfarin in the 150 mg. But believe me, of my patients who are on dabigatran most of them are on 110 mg. I will acknowledge that also. But if you look at the data definitely 150 mg is really you know like top of the charts and has shown a real good benefit over warfarin. So that I feel is the biggest argument for dabigatran. The arguments against dabigatran revolve around other issues that from day #1 there has been some controversy with resect to myocardial infarction with patients with preexisting coronary artery disease, with patients with (13:00) preexisting renal failure and more importantly in patients with acute coronary syndrome and more often as a practical if you are the patient or I am the patient any drug which is given twice a day always is a challenge in terms of compliance. Other than these two issues I think the dabigatran is the leader in the field. Rivaroxaban appealed to everybody because of the rocket AF data which showed a sincere superiority in terms of safety.
I would not say that rocket AF proved that rivaroxaban is superior to warfarin but at least when it comes to the safety data I think the safety data of rivaroxaban is very good and I feel the big clenching point about the rivaroxaban has been its safety with respect to myocardial infarction. So what happens is at the end of the day I am a cardiologist, so my bread, butter and jam everything revolves around (14:00) ACS. See I can always say that dabigatran data on myocardial infarction is tricky. But at least I can confidently say that data on rivaroxaban is so strong that I can say that even if it does not cause MI it saves more patients. So dabigatran at the end of the day I will say it is neutral where as rivaroxaban I will confidently say it is more positive. That is rivaroxaban shows a definite data in terms of positive benefits in patients with IHD. So today I would be choosing rivaroxaban in all patients whom I have a combination of IHD with atrial fibrillation. So I have stented a guy and then I need to treat his atrial fibrillation I would strongly, strongly think about it. Because I am not saying Apixaban is bad in IHD.
But if you see the data on IHD the only drug which shows a real good benefit in terms of risk reduction and mortality and all those issues (15:00) no other drug comes closer to rivaroxaban. Apixaban I would still have some reservations because I would call it the latest baby or new baby on the block. So data is coming up, I am not saying data is not there, it is coming up, but not as robust as rivaroxaban and dabigatran. So I am still little concerned about starting of apixaban. To put it in a nut shell if you have to analyze all my patients then the least number of patients would be on apixaban, may be I would say in double digits. So rivaroxaban may be more patients, may be 100 odd patients, but apixaban definitely in double digits, not more than that because it is new kid in the block. One of the key things I have noticed about apixaban is in terms of safety in older people some I think it scores slightly above the other two drugs. (16:00) So, may be if I am considering say an 80-year-old female with borderline renal function I think I may choose apixaban. I would rather wait, see like I told you about dabigatran and rivaroxaban, I have always waited. So I am strong believer in the philosophy you know never be the first to start a drug. Somehow I always believe that you know you should let the evidence distil down to clinical practice before using it. With dabigatran I have a clarity of mind, with rivaroxaban also I have a very good clarity of mind that these are the scenarios where I am going to look at rivaroxaban and use it in particular patient. With apixaban I am optimistic I am not saying that I am, see when you compare it with rivaroxaban, I know rivaroxaban is going to be dumped that is my gut feeling, may be the company may think I personally feel rivaroxaban may be dumped, but apixaban is not in that category. I feel that apixaban will give a good run (17:00) to these guys especially in a selected group of people.
Surely, definitely sir has given very in detail description regarding the practical challenges as well that atrial fibrillation definitely as of now whatever the number is, that totally may be under detected. So there is no assurance regarding that. Because sir has said very clearly when we open eyes then definitely what we can see that is our belief. So, that is why its accurate history and accurate incidence rate to find out regarding atrial fibrillation is very very difficult task. Second thing what he told regarding older oral anticoagulants regarding the VKAs. They have very practical challenges like the monitoring and drug-to-drug interaction and to convince the patients regarding that is also very difficult task. In depth what we have discussed regarding NOACs, newer generation oral anticoagulants, that is from the first drug like dabigatran, rivaroxaban and followed by apixaban and how we can utilize each and (18.00) every drug in utilization of the patient’s treatment is very well discussed. So with this note