Non-valvular Atrial Fibrillation rare in India

Due to lack of adherence to regular INR monitoring, most doctors end up giving suboptimal doses of anticoagulants, which may not be effective in stroke prevention

Dr. B Keshava Murthy


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Dr.Kunal Jhaveri

So sir today what we are going to discuss basically on there is one of the commonest arrhythmic disorder is atrial fibrillation and some part of the thromboembolic disorders also as well and what is the role of newer generation oral anticoagulants in particular these two kinds of the diseases. So sir as you know that atrial fibrillation is one of the commonest arrhythmic disorder but still the global prevalence rate if you see it is around 1.8 to 2%, in India I do not think as of now we have any established history that we can establish particular kind of the incidence rate of atrial fibrillation, so in your practice as a cardiologist, what you have found that the patient's incidence rate and the diagnosis of this particular disease, is it very regularly and frequently coming on time or not and if it is not happening, then what could be the possibilities.

Dr. Murthy

In terms of non-valvular atrial fibrillation, in India may be lesser than foreign countries because Western population live longer, they do not have rheumatic heart disease. We have more of (01:00) rheumatic atrial fibrillation, non-valvular atrial fibrillation is rare in India. Even in my busy practice, I do not see my case instance is a bit low. It is because elderly population even with coronary artery disease, atrial fibrillation incidence is low, that is my personal feeling.

Dr.Kunal Jhaveri

Okay, so it is low and also the detection of atrial fibrillation is also not happening on the particular time like the paroxysmal atrial fibrillation.

Dr. Murthy

Atrial fibrillation detection is definitely we have diagnosing them early and treating them, but non-valvular atrial fibrillation per se incidence is low in India.

Dr.Kunal Jhaveri

Okay, so if we talk about the risks and complications of the particular atrial fibrillation for one of the commonest thromboembolic disorder is stroke, it is associated with non-valvular atrial fibrillation as well (02:00) and regarding a stroke, as of now, the current treatment is available is vitamin antagonist, warfarin, they are available since almost last 50 to 60 years in India. So what is your experience on this particular group of drugs, in your practice how you have used in various kinds of indications apart from the SPAF and other thromboembolic disorders and what kind of challenges you have found in this particular treatment as well.

Dr. Murthy

Really, we put atrial fibrillation patient who are elderly atrial fibrillation patients, based on CHADS score we put them on oral anticoagulants, especially elderly woman who have got diabetics we tend to put them on anticoagulants in addition to aspirin or without aspirin, we tend to put them on oral anticoagulants but the issue is they will not be any regular followup for measuring the anticoagulant value like PT/INR, (03:00) it will be difficult for them to come for regular periodic check up, most of the time we end up in giving a suboptimal doses like we give 1 mg, 2 mg of warfarin for ______ which may not be very effective in real case of atrial fibrillation, non-valvular atrial fibrillation, and in preventing stroke.

Dr.Kunal Jhaveri

So definitely what you have said rightly that the practical challenge is a regular followup of the patient, especially the INR monitoring and PT monitoring is not possible even in the internal part of the India as well and that may the biggest challenge for this particular group of the drugs. So to answer them, the newer generation of oral anticoagulants are available like rivaroxaban, apixaban and dabigatran, so sir what is your experience on this particular group of the disease in various condition you must have used SPAF, deep venous thrombosis, thromboembolic disorder, so what is your experience of this group of molecules.

Dr. Murthy

I should agree (04:00) and accept that I have not used much of these drugs but one recent information for me is that rivaroxaban is indicated in case of pulmonary embolism and for followup we tend to give higher dose for 20 days and four months we give a lower dose, that is very attractive to me. Probably I tend to use in case we have lot of cases and we have at least one or two cases in my practice I have one or two cases of acute pulmonary embolism in my practice, so I though it will be worthwhile like giving these drugs which does not require anticoagulant monitoring, as well as may be more effective than the routine anticoagulants, in this group of patients I am planning to use them.

Dr.Kunal Jhaveri

Okay, so what about the stroke prevention atrial fibrillation, these all three drugs are also indicated in this group of the disease.

Dr. Murthy

Let me be frank that I have not seen a (05:00) stroke in a normal atrial fibrillation in past 5 to 6 years but because there are guidelines there is reported incidence of stroke, we tend to put the patient on oral anticoagulants to avoid legal issues, so that is why we put them on oral anticoagulants, no other reason but most of the time on suboptimal therapy, so such patients if they are affordable, I do not mind putting them on these pure anticoagulants but because the incidence is very low.

Dr.Kunal Jhaveri

Definitely, that is fine, now the thing is that you talk about atrial fibrillation, its detection is also very, very difficult, the screening part is also very less, so if you want specific important takeaway from your side for the patients even for the physicians and who have the DM cardiologist (06:00) regarding the atrial fibrillation and its management, then what is your choice sir. Suppose if you want to give some five important instructions to the patients then what instruction you will give for the atrial fibrillation and the stroke prevention atrial fibrillation for the patients.

Dr. Murthy

It is a very difficult question to answer because if CHADS score says that the patient is high risk of stroke or atrial fibrillation like the patient has got coexisting disease like diabetes, obese in little girls and woman then we should put them on oral anticoagulants. One of the choices would be newer anticoagulant which does not require an anticoagulant monitoring. Having said that whether they will comply with the higher cost of this drug is one issue in area which requires what you say experience (07:00) for a time but definitely if an affordable patient who requires with a high chart scores, I would love to try this drug.

Dr.Kunal Jhaveri

Regarding the CHADS score, definitely you can assess the patient those who are high risk for the stroke, now would you like to advise at physician level that though when the patient are coming with such kind of high risk conditions, like the age, myocardial infarction, and congestive heart failure, then you should go for some kind of screening procedures like ECG and pulse palpation method so that they can have some idea regarding this particular arrhythmic disorder and the treatment can be started as soon as possible.

Dr. Murthy

As such, most of the patients who attend to me or attend the physician, definitely India is a grown up country, it is a developed country actually for because I feel we in a small town like, we have crossed 1000 angioplasties in last three years, so (08:00) India is a developed country as far as cardiology practice is concerned. Most of them have an ECG, even in a small town taluk, subtaluk level we have an ECG and physicians are very well qualified to interpret an ECG and any MBBS student, MD physician will detect, find, and diagnose an atrial fibrillation, put them on drugs, probably they might put them on aspirin and may not put them on oral anticoagulants because of fear that anticoagulant monitoring is not possible in most of the places even the laboratory values which are reported are not really reliable, so in that condition if the patient can afford these kind of newer anticoagulants will have a role.

Dr.Kunal Jhaveri

So I think sir it a very fair discussion what we have and as the sir has suggested very frankly that atrial fibrillation is definitely it is a common arrhythmic disorder and India is one of the growing country, (09:00) so in this kind of countries also at that physician level they are getting diagnosed very maximally with proper ECG and proper pulse palpation method as well and I also tell given information is very frankly that regarding the VKS they are good available treatment but still due to the practical challenges like INR monitoring and proper followup, NOAC can be a better option and in affordable class definitely it should be a first of the choice. So, sir thanks a lot for being here and giving your valuable opinions and your time for this particular discussion. Thanks a lot.