Atrial Fibrillation: The most common Arrhythmia

General physicians should also be able to pick up Atrial Fibrillation by listening to the pulse or heart sounds for 30 seconds.
Dr. BRJ Kanna

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Dr.Kunal Jhaveri

So sir as we know that atrial fibrillation is one of the commonest arrhythmic disorder. It is almost in one third patients of arrhythmic disorder; it is finally diagnosed as atrial fibrillation. As of now in your practice, how common you have found atrial fibrillation disease in your brilliant practice?

Dr. Kannan

See you need not call it as one of the common arrhythmias, that is the commonest arrhythmia and atrial fibrillation, the etiology varies with the age. You know in the younger age, we have more of valve related problems, right now still rheumatic heart disease though the incident is less in India; still it is significant and in younger age if you come across atrial fibrillation, 90% of the time they have valvular heart disease, say less than 40 years or 50 years, but beyond 60 years or 65 years it is a nonvalvular atrial fibrillation what is more prominent. As you said rightly said nearly one third have, so we the cardiologist are not the ones to diagnose the atrial fibrillation. Actually the general physicians and the general practitioners should be (1:00) picking up the atrial fibrillation and though ECG and so many other things are mentioned mere listening to the heart sounds for 30 seconds to one minute continuously is enough. Just merely listening to the pulse or heart sounds continuously we can easily diagnose the atrial fibrillation and hence whenever any doctor comes across any old person for any reasons, we should make it a habit to keep a hand on the pulse to just listen to see whether it is an irregular heart rate. If it is irregular heart rate and he should be alerted for the possibility of atrial fibrillation. So it is not that uncommon and now it is very common and once you identify properly you are going to prevent a major catastrophe.

Dr.Kunal Jhaveri

It is also very well established that stroke is the one of the thromboembolic disorder which is very commonly associated with atrial fibrillation (02:00) and for the primary prevention of the stroke based on various risk categories antithrombotic treatment and sometimes we also found that that the patients are treated with oral antiplatelets for prevention of stroke. So sir what is your take on, on this particular aspect and whether we can use this oral antiplatelet like aspirin, clopidogrel?

Dr. Kannan

No the answer is no. It does not prevent. In atrial fibrillation, antiplatelets they do not prevent stroke, they only give the side effect of bleeding to the patient. So we should not be using antiplatelets for treating atrial fibrillation; it is only anticoagulation.

Dr.Kunal Jhaveri

So as per your suggestion oral antiplatelets should be avoided for the primary prevention of the stroke so the remaining part is oral anticoagulants. So this conventional oral anticoagulants are available since last almost 50 to 60 years worldwide and even in India as well. So have you been happy with this particular kind of the group of the drugs for the stoke prevention and atrial fibrillation.

Dr. Kannan

See we have been using warfarin conventionally and the other phytomenadione also, but I wound not say I am very unhappy, but that does not suite everyone; like if you treat and sincerely do the prothrombin time in same lab, same hospital and follow them up and you can see as high as 30 to 50% of the patients it is very difficult to get the expected INR with the same dose, so they may be under treated where the INR value will become very low and with slightly increase the INR value will go very high and second thing that it necessitates the patient to come to our lab and get it checked. It is not like for example if your monitoring sugar levels; you can say ok get your sugar at your local lab call me one week later, I will adjust over phone; like that kind of thing is not possible here because it is not a routinely done investigation and very few labs have standardized. I think that is the bottleneck of treatment. Jut not the drug, the bottleneck is to identify whether the drug is acting properly or not point #1. 0:04:07.8 Point#2, because of the varying food habits, which has lot of influence on the drug levels of the body, but I can say nearly 50% after some two or three will have a stable level with a stable milligrams they all are being well, but the other half we always had this thing in the mind can there be a better drug. So in that way this NOVEL oral anticoagulants have really helped us.

Dr.Kunal Jhaveri

So definitely one point what you mentioned that if atrial fibrillation is one of the age related disorder, so now this is the one very regularly what we have seen in the practice from the physicians and cardiologists as well as when the age is getting more than 75 or it is older patient and patient is developing atrial fibrillation, then there is some hesitation that has been found to use the oral anticoagulants and sometimes NOACs as well. So what is your suggestion on this particular concern that shall we go a head 0:05:06.1 with these kind of the drugs or we should find some another way to treat the patients?

Dr. Kannan

See this inhibition is there in everyone because everyone in mind they think older the patient, high risk chance of bleeding with any anticoagulation, which is not true. On the other hand, the older the patient, the benefit is more with anticoagulation. If you see the studies whether it is a warfarin or related study or with a newer oral anticoagulation, it is the aged patients who are more benefited with the drug than the younger patients. So actually this will be totally the reverse, if a younger patient comes one can take a chance and wait and watch, but if an older patient comes there is nothing like taking a chance, you have to give. So there is a definite indication. One has to give oral anticoagulation even somebody is 85 years. So the thing is you cannot argue he is already old why should I treat and all; that is secondary, but as I said older the patient, higher is the benefit from anticoagulation if it is atrial fibrillation.

Dr.Kunal Jhaveri

Sure, age definitely it is a major concern, but you should not worry for this age as a bar for the hesitation of the treatment in this.

Dr. Kannan

And the second thing is higher the age is not equivalent to higher in sense of bleeding, which is not true.

Dr.Kunal Jhaveri

So sir we have seen there is one step by step changes for the treatment from oral anticoagulants to the newer kind of the oral anticoagulants. So how will you welcome this kind of the concept of the newer anticoagulants as you said that the monitoring of INR and PT is one of the major practical challenge when patient is on the VKs and the warfarin and acenocoumarol. So do you find that this kind of the practical challenges and the problems can be resolved with this kind of newer kind of the generation and will you welcome this?

Dr. Kannan

Ya that is what, it is a welcoming change. It is welcome new drug, if you see the armamentarium of cardiac drugs very few places we were expecting some new drug to come. So in that way as I told, if this drug is very effective in more than 80% of patient’s which I said 0:07:05.1 with oral conventional warfarin was around 50%. So it is a real welcoming change so this drug was really needed. So it has come and we have to really use it for the benefit of the patients.

Dr.Kunal Jhaveri

Surely, so definitely you must be using in your patients so can I know that in your regular practice what percentage of the A patients have benefited with this newer concept of oral anticoagulation.

Dr. Kannan

If you ask me that question, I think if I take only the non-valvular atrial fibrillation should be above 30%.

Dr.Kunal Jhaveri

Ok and even in that can we differentiate there are three NOACs available. rivaroxaban dabigatran and apixaban. So what will be your peripheral choice or you might change your treatment pattern based on the different condition of the patients.

Dr. Kannan

Actually, practically speaking the difference is small. In some studies in some way there is a slight difference, but whether that can be really translated in the real world and whether 0:08:03.0 really it is applicable to given patient we do not know because there has been no head to head comparison between the oral anticoagulation. See based on in this study, this group of patients did better in that study that small group was better. So based on that, we cannot say this is better in this aspect as compared to that drug. So right now our take has been that most of the oral anticoagulation right now unless we have used for another two to three years we will not be able to form our own ideas. Right now whatever idea we get is from the studies and according to the studies right now there is nothing no strong reason to differentiate between the three.

Dr.Kunal Jhaveri

Sure that is very well said from your side sir. You must have said that these NOACs can be use in A kind of the patient, but still you have said that not all the patients are on these particular NOACs, so can we have that kind of the reason that why all of the patients are not on this particular kind of newer concept?

Dr. Kannan

Ya why not all of them are not using this, you can tell me the answer, you know the answer what is the reason.

Dr.Kunal Jhaveri

As of now what we have discussed with the other practitioners and the medical fraternity most probably reason is the cost.

Dr. Kannan

Exactly, exactly most probably that is the only the reason. It is not the non-availability, it is the cost. Now whenever I started treatment; suppose I am going to start a very costly antibiotic which is there for one week or 10 days or 15 days, I am not going to really check the cost, if it is very effective I am going to ask the patient to buy that because it is only 10 days or 15 days therapy he also wound not mind, but if I am going to prescribe him a drug which he has to continue for lifelong therapy he has to commit himself that he is going to take it continuously, it is not like you take for three months and then subsequently we change to some other. It does not work. So, right now the problem is that of course first I will see whether is an indication, second thing I have to discuss with the patient whether he is willing to purchase it and use it indefinitely. The advantages I will tell him that he need not visit our hospital. He not get that medicine checked and the investigation being done and then 0:10:07.8 there is a overall difference that it is better than the older drug, all advantages I do say, but if he is not committed to spend that much money every month then there is no point in starting. I will never experiment like you know you just try three months and than tell me your answer. No how can he tell his answer or how ca he tell his experience. No, it is not. So the main level of filter is at this level. So after explaining him the availability of newer drugs, I will ask his commitment, if he says yes doctor I will definitely try to continue as much as possible then I will start. So whomever I have stated all of them have been continuing still now. In one of the husband and wife both of them are taking. Ok so the thing is right now the main problem is the cost, if the cost comes down definitely it can be expanded to wider range of patients.

Dr.Kunal Jhaveri

Definitely, it is very well said that cost is a factor and even in spite of that proper counseling 0:11:04.5in patients regarding commitment of the treatment that whether he will continue for longer time, then and then we should go such kind of the treatment, otherwise as you said patient will not be benefited and unnecessarily might land up with some kind of adverse events like that. So sir there is one more question is that as a cardiologist definitely primary prevention of stoke is very important and if you talk about other medical fraternity group as a neurologist when the patient is developing a stroke and retrospectively he is diagnosed with AF, so this kind of the treatment will be applicable at both the side, primary as well as the recurrent prevention of a stoke. So this molecule will go in which hand whether it is a cardiologist or in a neurologist.

Dr. Kannan

See the thing is to decide on starting the treatment could a cardiologist or neurologist, but subsequently, the patient need not be followed only with these two people. So if the general practitioners also have been told about these patients they themselves can follow up, follow up means what insuring the complaints. See if you simply say ok continue take his drug come after one year that compliance is going to go down. He may take for one or two months then he will start leaving a gap of two to three days then the gap will gradually increase. So the one reason why doctors ask the patients to come back at regular basis is that many attempts I would not change the single prescription I will be giving the same prescription again, but only thing is I would have spoken to him, I would have asked about the disease and I would have ensured that he has been taking that drugs and he will also continue to take so that kind of thing a general practitioner or a general physicians level itself can be done. See they should be told about the disease. They should not hesitate to continue to prescribe the drug and ensure so the decision to start could be wit cardiologist and neurologist, but the decision to continue or the regular follow up need not always be with these two people because it may busy or they may be more costlier 0:13:04.3 compare to following with a local physicians. So that should be our take up actually on this issue.

Dr.Kunal Jhaveri

Definitely sir, this is a really a good thought of point that these drugs should go beyond the cardiologist and neurologist level. It should be at GP’s level, but they also have to ensure that regarding the compliance level and some safety aspect of that so how they can take along this particular kind of treatment. So thanks a lot sir for your final take on that. If we talk about major take on points from Dr. Kannan is that AF is definitely is a major concern of our society, previously there are the older anticoagulants are going to use, but they have some practical issues like INR monitoring and also the longer compliance and in case of that the newer oral agents are also available. They are better, they must be effective and safe, but again the cost is a major hurdle that each and every patient is not going to be benefited with this particular kind of treatment and the one important though also is raised that we should go beyond the cardiologist and 0:14:04.3 to spread the education, awareness and scientific awareness of this particular drug at the GP level as well. So thanks a lot Dr. Kannan Sir for providing your time and valuable comments on this particular thing

Dr. Kannan

Thanks