New Oral Anticoagulants (NOACs) are safe, efficient, but expensive

NOACs are ideal for the elderly with non-valvular Atrial Fibrillation

Dr. Amal Banerjee

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Dr. Amal Banerjee

Actually, the issue is that atrial fibrillation in India the prevalence of atrial fibrillation is increasing in India years after years. Atrial fibrillation, the most important issue, the first step of atrial fibrillation is the prevention of thromboembolism. What we say is that any patient having the atrial fibrillation more than 48 hours, he should receive the anticoagulation, that is the protocol is there; if we have some CHADS-VASc score. With this scoring, any patient having at the score of 1 then the patient may have the only antiplatelet aspirin, the two option is the patient may have gone for the dual antiplatelet that the people liked or aspirin or they go to oral anticoagulant but the score more than 2 he should (1:00) and must receive oral anticoagulation. Now for the age old who are having the vitamin K antagonist that is warfarin, it is a age old drug that we are using very-very long time but there are some issues. For the monitoring of the warfarin, we required to go for INR study, we take a followup for INR regarding monitoring the anticoagulation status of warfarin. Apart from that, the patients particularly many patients who require say they are having the atrial fibrillation in pregnancy. Warfarin embryopathy is a dreaded particularly if the pregnant patient they are instituted warfarin in the first trimester. Now, in that area also, we have some problem, so to counter this problem newer anticoagulants have come, we have the (2:00), rivaroxaban, dabigatran, and also apixaban; they have enough study but issue is that these particularly when compared with warfarin, this newer anticoagulants they have the least cerebral hemorrhage and other bleeding complications but in India particularly in the younger age group we have two substance of patients who are having atrial fibrillation, one is the prosthetic one, another is the patient with rheumatic particularly mitral stenosis and the rheumatic valvular disease; particularly in this areas newer anticoagulants they are not indicated. Anyway but patients who are having other group - elderly age group, non-valvular atrial fibrillation, they are the scope for (3:00) using the newer anticoagulants. Now, from my personal experience, since dabigatran is available for the long time, I personally was using dabigatran but we have some reports that dabigatran they have the increased gastrointestinal hemorrhage and also they have some increased or non-significant increased incidents of coronary artery events just like acute myocardial infarction, so now before I institute any patient with dabigatran, I will think twice whether I will go for the dabigatran. My next choice as from the complication within bleeding complication, cardiovascular complication other than or my next is rivaroxaban but issue is that (4:00) that the rivaroxaban or dabigatran they are very costly in our country but you know when we use drug our three issues we consider, first is the safety, second is the efficacy, third is the cost. All these newer oral anticoagulants they are safe, they are efficacious, but cost is high; we consider the socioeconomic particularly economic status of India, so those patient who can afford now I use or my option would be to use rivaroxaban or apixaban or this drugs are though not very easily available but my option will be the rivaroxaban, so I think those particular substances of patients who can afford (5:00), who are not the result of the atrial fibrillation not from the rheumatic valvular disease, who are not having the prosthetic valve, in this particular group of patients my option would be going for the particular rivaroxaban. They have the advantages, that they do not require any monitoring but the problem is that if this group of patients if they have bleeding particularly the close bleeds like intracranial or intraspinal now for the GI bleeding, we can manage the GI bleeding very well but if they have got intracranial bleeding or spinal bleeding will be very difficult though rare compared to warfarin. There is less bleeding with the newer anticoagulants, intracranial bleed. So I think that it would be good option for those you rather says that now I have interacted the people who are doing this. I prefer (6:00) that all, non-valvular particularly India, that the non rheumatic patient, not non-valvular, you know that this is a paradox the patient having in western country having the calcific aortic stenosis they consider it as to be the non-valvular even the patient with hemodynamically insignificant valvular lesion, they consider is non-valvular so except rheumatic valvular diseases and prosthetic valve, we may go for the newer anticoagulant. (7:00).

Dr.Kunal Jhaveri

Thanks a lot, so we have good insight from Dr. Amal Kumar Banerjee who is currently associated as a consultant interventional cardiologist from Kolkata and he has already very good role in the Cardiology Society of India as a president and also he was the past president of API and also was associated with the SAARC CSI. Thanks a lot for your valuable opinions and comments.