Stroke prevention in Atrial Fibrillation

Ageing and comorbidities like hypertension, diabetes and obesity have increased the incidence of non-valvular Atrial Fibrillation
Dr. Rakesh Gupta

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Dr.Kunal Jhaveri

Today we have one of the renowned clinical and non-invasive cardiologist, Dr. Rakesh Gupta who is from Jaslok Hospital based in New Delhi. Sir it is a warm welcome for the Revolution talk. So, sir, as you know that in arrhythmic disorders, arrhythmia is one of the commonest disease having the incidences of around 30-33%. So you have such a vast experience and so in your routine practice how do you look at atrial fibrillation from the diagnosis point of view.

Dr. Rakesh Gupta

If I have to look for atrial fibrillation for a diagnosis practice, take my words, single simple most important test is electrocardiogram, practically available every nook and corner of our country which can be done even by a basic medical physician who can diagnose atrial fibrillation (01:00). No big machineries are required. No big gametes are required. No big color Doppler machines are required and that said, the simple test is ECG. One point I would like to make in this point is we should always take a rhythm of ECG at the end of doing an ECG so that we categorically say that the patient is in atrial fibrillation and lack of presence of T waves in ECG is characteristic diagnostic of atrial fibrillation.

Dr.Kunal Jhaveri

Perfect, so I think it is not so much difficult. ECG is available everywhere, now in the corner of India also the ECG machines and even the physicians are also now well aware of this very particular plan.

Dr. Rakesh Gupta

Very well trained and aware of it.
Dr.Kunal Jhaveri: So that should not be an issue, but now, the thing is that what could be the possible etiological factors for the development of atrial fibrillation.

Dr. Rakesh Gupta

Well, India has been a largest country (02:00) which has seen atrial fibrillation for the last 60 to 70 years. The reason for a long time was valvular rheumatic, rheumatic heart disease was prevalent in that country, it is still prevalent in our country. So we can broadly define this atrial fibrillation into non-valvular and valvular. We have seen valvular atrial fibrillation because of rheumatic heart disease given rise to mitral stenosis, mitral regurgitation, large left atrial dilatation, and given rise to atrial fibrillation. Over a period of time, as the prosperity developed in India we have seen more people suffering from non-valvular atrial fibrillation all because of aging, life has become bigger, longer and healthy also, and maintainable if we develop some illness. So aging, hypertension, diabetes, obstructive sleep apnea, hypothyroidism and most important thing is obesity (03:00), all these factors have led to further a new category of atrial fibrillation which is known as non-valvular atrial fibrillation which we have started seeing for the last eight to ten years now, more commonly.

Dr.Kunal Jhaveri

So definitely sir you have mentioned very well the non-valvular and valvular two parts of atrial fibrillation and now because of awareness of disease and with long age and multiple comorbid conditions, non-valvular atrial fibrillation incidences are also increasing now by leaps and bounds. So regarding the non-valvular atrial fibrillation, as for the data, one of the commonest complication is the stroke. So, how do you find that when the patient has non-valvular atrial fibrillation and the chances of developing stroke with various risk factors. What is your experience?

Dr. Rakesh Gupta

Certainly if a person of all these comorbid (04:00) conditions, if they develop an atrial fibrillation, there have a very high chance of developing a stroke. Everybody knows this fact, lot of data is available which need not be discussed at this platform, and if they develop atrial fibrillation and they develop a stroke they have a lifelong comorbidity which the people have to carry on for a longer time. Our question is how can we prevent that stroke because of atrial fibrillation. First thing is either we revert the atrial fibrillation to normal sinus rhythm, give them anticoagulant and say thank you but this has to be done with correction of a comorbid condition like control of hypertension, diabetes, obesity, sleep apnea syndrome and other factors. Obviously aging cannot be controlled in any way. We can only modify aging by remaining healthy and adopting a good lifestyle. Especially in this kind of people who are aging and (05:00) they have atrial fibrillation, we want to prevent stroke by giving them conventional or a newer anticoagulants where the slang language has come as new oral anticoagulant so that they are prevented for getting that unusual or preventable complication of atrial fibrillation.

Dr.Kunal Jhaveri

Okay, so definitely you have mentioned that regarding the management part the control of atrial fibrillation is very very required. So the first chance what you will take to revert the atrial fibrillation to the normal sinus rhythm and meanwhile you should start the oral anticoagulants whether, initially there was vitamin K antagonist, now the newer generation of oral anticoagulants are also available. But sometimes in your practice you must have also found that you have tried very aggressively and tried to revert the patient to the normal sinus rhythm (06:00) but sometimes it may fail. So in this condition, you have also mentioned that stroke prevention is very very critical and very very required also as well.

Dr. Rakesh Gupta

In fact, if you look at the true scenarios of stroke prevention in atrial fibrillation, anybody who is more than 65 years of age we have to give them anticoagulants. So if somebody does not prescribe it is not being an ethical practice.

Dr.Kunal Jhaveri

So in this condition, where the patient is not reverting to the normal sinus rhythm and still you have to do the treatment for the stroke prevention in atrial fibrillation, what could be your management.

Dr. Rakesh Gupta

Well, till date, like I can say that we have been using time tested vitamin K antagonists from a long time. They are very good, time tested, lot of data which is available on them but the most important thing is we have to maintain their INR (07:00). Incidences of bleedings are pretty high. Compliance of a patient is equally bad. I do not say that everybody is not compliant, lot many people are compliant but apart from taking the drug, they have to get their regular INR done, which INR monitoring is not easily possible if we are looking for a diagnosis of atrial fibrillation at a corner of a country, corner of a state in India, where the facility itself is not present and even if the facilities are present they are not up to the mark for detection of proper INR levels. This is my specific word. This is what we have been facing, what exactly happens if the patient is taking this old prior generation vitamin K antagonists, what exactly happens, they have been taking a drug but they are not able to maintain their INR. On the contrary, they have to look at many food habits which they have to go for it or avoid (08:00). They are also unable to do it. So either they are left with lower INR levels or they go to higher INR levels in turn, on one side the drug is not effective, on the other side this gives rise to bleeding complication. That is why I feel that newer generation oral anticoagulants have some large role to play definitely in a county like ours.

Dr.Kunal Jhaveri

So it is a very practical point that you have raised that oral drug available, they are effective but monitoring of INR is a biggest issue in India and the new oral anticoagulant may be the best solution. If they are the best solution for the prevention of stroke and atrial fibrillation. So sir in India, since the last five to six years, different types of new oral anticoagulants are available like dabigatran, rivaroxaban and apixaban. You must have used all kind of drugs in your current practice. What is your experience with these different drugs (09:00)? How you are going to individualize, suppose if you choose one newer generation for this patient, then what is your criteria?

Dr. Rakesh Gupta

Look while choosing a new generation oral anticoagulants drugs I have to look for a couple of things. The first and foremost thing is the compliance of a patient in the form like how many tablets he has to take one day. Second the cost of the drug, what is the average cost for the drug for the patient. Third, do I have to really look for the INR in this subset of population. So these three criterias will make lot of difference because they have to take this drug for lifelong. If I am looking in an aging person, who is in atrial fibrillation it is not going to be a drug for one day. I say drug to eternity for him. So all these factors make lot of difference and looking at all these three drugs which you have quoted a couple of minutes back, I feel like couple of drugs which have really made mark is, one of them is rivaroxaban (10:00) which is really a good drug, one time in a day, no need for monitoring INR but the cost is little prohibitive as of today, and I am sure as the time goes on more and more drugs are being consumed, so obviously things will come down really convenient for the population at large.

Dr.Kunal Jhaveri

So Dr. Gupta has said very very well and in detail and there is actual practical scenario in Indian condition regarding the atrial fibrillation and the stroke prevention. Older generation molecules are effective, they are good but the INR monitoring is not possible up to mark in corner of each and every part of India and to replace or to give better solution for them new oral anticoagulation is better solution but again for better compliance and lifelong treatment the cost is also one of the biggest factor, so that is also one of the considering factor when you are using the new oral anticoagulant in atrial fibrillation patients. So with this note, sir, we are ending our discussion and thanks a lot for your valuable comments and expert opinion.

Dr. Rakesh Gupta

Thank you very much and we look forward to have something more.