New Oral Anticoagulants for Stroke prevention

Rivaroxaban prevents stroke incidents to a large extent and its bleeding risk is also very low.
Dr. Shivrajan

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Dr.Kunal Jhaveri

Today we have the stroke neurovascular consultant Dr. Shivrajan from Oxford University and currently he is associated with Apollo Hospital, Chennai. Sir it is a warm welcome for this particular our show and revolutionary talk. So sir we have lot discussed regarding the atrial fibrillation from the cardiovascular point of view. Now neurological point of view also we want that the stroke is definitely one of the major concern. As a neurologist you have found in your patients but always we are talking about prevention, prevention, and prevention of a stroke in AF patients, so according to your point of view what is the importance of a primary prevention and if it is not happening then what is the need of a secondary prevention of stroke in AF patients.

Dr. Shivrajan

From stroke point of view, TIA mini strokes or ischemic strokes, atrial fibrillation is one of the main causes which cause a stroke and unfortunately it is not picked up well enough <1:00> in the general population and even if it is picked up not all of them end up getting the right treatment. So until recently Warfarin was the main stay of treatment but with the arrival of the newer anticoagulant especially rivaroxaban which is easy to take because it is once daily preparation, it is going to change the whole scenario of the anticoagulation. In terms of primary versus secondary prevention, I think compared to lot of trials that has been done looking at primary prevention and so on, aspirin versus warfarin clearly sort of prove that anticoagulants is the way to prevent a stroke with somebody who has atrial fibrillation. We have got multiple clinical studies looking at anticoagulation versus antiplatelets. Recently with the arrival of all the NOACs, their rocket AF trial clearly demonstrated benefit, non-inferiority versus warfarin and also the expert trial confirmed the use of <2:00> rivaroxaban prevents pericardioversion, stroke incidents to a great extent. As we all know, it has been approved in DVT prophylaxis, knee and hip replacements and so on, and definitely the bleeding risk is comparably very low compared to Warfarin, so I am a big fan of rivaroxaban.

Dr.Kunal Jhaveri

Okay, definitely, so it is a very strong point put on rivaroxaban, that it is one of the good molecule for the secondary prevention of stroke as well and as well as the primary prevention and DVT treatment and prophylaxis part also as well.

Dr. Shivrajan

So in terms of secondary prevention, obviously it depends on the size of the stroke, if somebody has a big stroke I would wait for up to 12 to 14 days and then reevaluate to see when it can restart. If it is a mild stroke like TIA or mini stroke, I would even start within 24 to 48 hours or up to seven days after and as you know there are patients who may have <3:00> hemorrhagic stroke but still have atrial fibrillation. In those patients we still have a little fear causing major hemorrhage. In those patients it has to be evaluated on a case by case basis and then a decision has to made very carefully.

Dr.Kunal Jhaveri

Definitely it is very well said. The second concern regarding that when the active ischemic stroke is developed in AF patients then there is definitely two kind of managements, one is medical conventional part and also surgical part also as well. So, according to your point of view, how you will stand both kind of treatment for the treatment of stroke in AF patient.

Dr. Shivrajan

When you say medical versus surgical, surgical part is very little, the strokes that need surgical intervention are like hemorrhagic stroke or patient who have subarachnoid hemorrhage and so on. In minority of ischemic stroke patients who will develop malignant MCA syndrome where the whole brain swells up, they may need a hemicraniectomy. In those patients obviously, it is not advisable to start anticoagulants <4:00> right away. In those patients we would bridge with a similar factor X inhibitor like heparin and other molecules to tide over the quick phase and then we can carefully restart it. Obviously you have to take everything into consideration like the renal function, liver function, patient’s age and other drug interactions that can be affecting the drugs metabolism, but so far we have not seen major negative impact with the newer oral anticoagulants, so I think if you chose your patients carefully and monitor the coagulation profiles, it should be fine.

Dr.Kunal Jhaveri

Okay, so I think it is very well crisp but in detail discussion regarding the secondary prevention of stroke in AF patients. So the NOACs has a very good scope in this particular segment also, though already patients when neurologist part is also there, the patient is coming with a stroke and you have <5:00> to find out the retrospective that the patient is landing up with AF or not, but still in this kind of patient there is a very high chance of recurrence stroke as well and to prevent that recurrent stroke then NOACs has one of the major role and sir has put very well point on the rivaroxaban that with the rocket AF data available it can be a better option as compared to the other NOACs. Regarding surgical aspect and medical management, the medical management still is under on the side as compared to the surgical segment where there is hemorrhagic kind of stroke then surgical role is much much high as compared to the NOACs. So sir with this note we are ending our discussion, so thanks a lot Dr. Shivrajan for providing your valuable comments and your expert opinion on this particular subject. Thank you.