Atrial Fibrillation: New Oral Anticoagulants are safer but expensive

Stroke and bleeding are two complications that may occur when INR levels are not maintained.
Dr. S RamaKrishnan

Supported by an Unrestricted
Educational Grant from


Dr.Kunal Jhaveri

Today we have one of the renowned cardiologist from the institute of All India Institute of Medical Science, Dr. Ramakrishnan who is currently associated as an additional professor of Cardiology at AIMS. Sir, it is a warm welcome for this particular revolutionary talk show. As we know that in the cardiovascular segment, now the concept of prevention of disease is now very well doing that everyone is trying that before happening of a disease it should be prevented. So, that chances of morbidity and mortality is very very less. So, from your experience so far, how you will implement this kind of concept in your practice as well.

Dr. Ramakrishnan

We all have been saying that prevention is better than cure and always like genius always will prevent the disease and so on and so forth, but when we come to implementation, it is becoming extremely difficult. So exactly what should be done, what exactly should be done, all those things are not very clear in Indian context. So, some of the efforts of cardiologist of the India has been to simplify that (01:00) and one of the thing that we have come up with is we have simplified, to prevent heart attacks and heart diseases, we need to say no to six S. So those six S’s are salt, sugar, smoking, sedentary lifestyle, stress and saturated fats. If you say no to these six S’s automatically you will prevent lot of heart diseases including hypertension, heart failure mainly coronary artery disease, heart attacks, angina as well as atrial fibrillation.

Dr.Kunal Jhaveri

So, definitely as you shared regarding the major factors like dietary factor and lifestyle factors, if we can modify then prevention of the cardiovascular disease can be better as of our current condition. One condition also is there regarding the arrhythmic disorder of atrial fibrillation where its complication of stroke. It is prevention is also very much required (02:00). So, when the patient is diagnosed with atrial fibrillation, then the stroke prevention in atrial fibrillation, the new term as a SPAF is now very much common for the treatment part. For the stroke prevention in atrial fibrillation, from the since years, there were oral anticoagulants and now followed by there is antiplatelets and now the new generation of oral anticoagulants are available. So, in your practice sir, you have come across all three molecules one by one. So, what you have found the clinical data of this particular drug and how it is helpful in your clinical practices.

Dr. Ramakrishnan

I think clearly atrial fibrillation is a disease where atria is chaotically contracting. It is not contracting in a uniform pattern, and there is a kind of recess which is kind of an appendage structure that is not useful as such to heart function, that is called the left atrial appendage. There is stasis. Because since the atria is not contracting, there could be formation of clots inside that. Clots always happen when there is stasis and the blood is not pumped forward there is stasis, immediately clot forms (03:00). The problem with atrial fibrillation is when such a thing happens, suddenly the patient can come back to normal rhythm immediately. In such a situation suddenly a clot may form and immediately once upon return to the sinus rhythm and otherwise also this clot can embolise to any part of the body. If it goes to any of the brain arteries, it produces what is known as stroke or TIA. The stroke can be devastating plus at times stroke cannot be completely curable and it leads to lot of damage and lot of morbidity to the patient. So, stroke has to be prevented. So, because everything is happening because of stasis and clot formation, it has traditionally been oral anticoagulation that means blood thinners. We thin the blood so that clot forms less has been the standard care of therapy. But the problem in Indian setting is that not many patients are educated. There is a serious problem of monitoring because this particular drug, the oral anticoagulations have a serious problem. They have very narrow therapeutic range(04:00). So, that means there is an effect range and there is a complication range. Here the effect is prevent clot formation and stroke and the complication is bleeding. So, there is a narrow window between preventing a clot and bleeding to happen. So, this drug needs constant monitoring by a blood test known as INR. So, this is international normalized ratio which blood tests are available across the country, but the problem in India is that across the country the tests are not standardized and not uniform. So, that has been a serious problem. We have a lot of patients who come back with us who did not maintain themselves in a good therapeutic window INR and there are a lot of patients who despite having maintained INR develop a stroke and those lot of patients who come with INR which is very high and some of them do present with bleeding complication. So this has been a problem, more so in our country where I think patients are (05:00) less educated and they do not follow the advice and they do not get the INR done, even at times they get the INR done at times, the INRs are erroneous because this particular test, lab to lab variation is there. So this has been a serious problem. So the advantage of this newer oral anticoagulation is that they are shown to be slightly more effective than the traditional agents and they are shown to be safe, but the major problem in our country is the cost. They are slightly expensive. They will be clearly much more expensive than the ones that we have been using, but regarding the efficacy part, they are well proven, large

Dr.Kunal Jhaveri

Okay, so I think that a very well point is covered that practically with the vitamin K antagonist and how the NOACs can be a better option against the vitamin K antagonist. Sir, if a choice is given to you that you have to select one of the NOACs, as of now three NOACs are available, rivaroxaban dabigatran and Apixaban (06:00), what are the selection criteria so that you can give these drugs to the patients.

Dr. Ramakrishnan

As of now, it is very difficult to say which one is better and which one is not better. I think it would be, as of now, there is no recommendation, I think all the three are good if you go with the guidelines and criteria and the trials that have been done. Across the trial, if you try to compare, it is a difficult comparison and it is often meaningless if you compare across the trial. The populations are different, the risk groups are different, so as of now I would say that it would be a difficult choice and may be once a day therapy, this could be a rivaroxaban could be some advantage where compliance becomes slightly better. So apart from that, I would not say that one is superior to the other.

Dr.Kunal Jhaveri

Surely, okay, so I think it is very in detail discussion regarding the stroke prevention in atrial fibrillation. So what are the current challenges with older anticoagulants and now what are the advantage of the newer oral anticoagulants(07:00). So, there is no head to head comparison against all three NOACs that are available. So, it may have some individual criteria to give such kind of NOACs to the AF patients for the stroke prevention. So, I think with this note we are ending our discussion. So, thanks a lot Dr. Ramakrishnan for providing your valuable comments and opinion.