New Oral Anticoagulants (NOACs) to prevent strokes effectively

Complications like Hemorrhages are more common with conventional anticoagulants than with NOACs

Dr. CU Velmurugendran


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Dr.Kunal Jhaveri

Hi Sir, today we are going to discuss the atrial fibrillation and its major complication of stroke. So as a neurologist, you must have found that majority of the patients definitely will come after the attack of stroke and retrospectively you will diagnose that the patient might have atrial fibrillation which is one of the major complication. Even for the primary prevention what we observed that the majority of the patients are not properly aware of this particular kind of disease, so that is why they are getting a late diagnosis of atrial fibrillation after having some kind of complications. As per your vast experience what kind of the massage should deliver to the patients and physicians as well so that we can diagnose this particular disease on time?

Dr. Velmurugendran

: See most of the patients who come to the intensive care they get admitted to the stroke unit where their pulse rate is monitored, heart rate is monitored (1.00) then we can easily find out the atrial fibrillation. Particularly we suspect cardioembolic stroke. It is a must to monitor them for a few days and then while you are monitoring you are likely to pick up lot of cases of atrial fibrillation, but then many cases may be missed. So those cases have got to be watched for a longer time probably with a Holter. For example in the case of transient ischemic attacks, few patients may come with transient ischemic attacks we may do all tests which may turn to be negative. Such patients perhaps are cases of atrial fibrillation. When I say atrial fibrillation, I mean the nonvalvular type of atrial fibrillations. Above the age of 60 to 65, I think it is mediatory that you should look for atrial fibrillation. So we will have to do a Holter monitoring of these patients. Some times in 24 hours we may not pick up the atrial fibrillation, (2.00) so we will have to monitor them for at least a period of one month to two months. So the electrodes are available which are in the form of a small patch which can be put on the chest and then they can take bath, they can move around and every week it is removed and new patches are put. So that means we will monitor them for a period of four to eight weeks. I am sure if there is an atrial fibrillation it will be picked up. Even transient atrial fibrillations will be picked up. It is very mandatory because we can prevent the further strokes by that and a stroke secondary to atrial fibrillation are always more dangerous. They produce more complications and deaths are more common after the atrial fibrillation because it can occur recurrently so in order to correct the atrial fibrillation to one end and prevent the stroke from other end.

Dr.Kunal Jhaveri

I think Sir you have mentioned a very well point that if patient had a prior history of TIA or stroke, then the recurrent chance of the stroke and TIA is very, very common (3.00) and I think based on that in CHAD-VAS score also as well as prior history of stroke given two points as compared to the other parameter which is only one point. You also mentioned that the stroke is one of the major complications in atrial fibrillation and there is five times higher risk of developing a stroke when the patient has already atrial fibrillation. So as a neurologist when the patient has already developed an acute stroke when it comes to an emergency then definitely it is very difficult to manage these kind of patients so as of now what is your clinical experience in this part?

Dr. Velmurugendran

: If the patient is diagnosed as atrial fibrillation even before he develop stroke it is important that we put them on anticoagulants apart from correcting the atrial fibrillation by way of cardiac tricks. So an anticoagulant is very necessary. There are varieties of anticoagulants that are available. One is the conventional anticoagulant like the vitamin K antagonist (4.00) and the other one is modern NOAC. Already three kinds of drugs are available in our country and they can be used.

Dr.Kunal Jhaveri

As per the data what is the available of the NOACs, and the rivaroxaban, dabigatran and apixaban. In rocket of trial, you can see there is 55% of the patient having the prior history of the stroke. So that kind of patients already treated for secondary prevention of stroke. So how will you take on this that because in your cases when the patient is coming already with a history of stroke then how will you place the NOACs for the treatment of this kind of the patients.

Dr. Velmurugendran

If the patient has already got an atrial fibrillation, then I think we will have start immediately the NOACs as a secondary prevention of stroke. It is mediatory to do that.

Dr.Kunal Jhaveri

The one more thing is that in acute ischemic stroke there is a role of fibrinolytics. (5.00) So do you consider this kind of treatment in the management of this?

Dr. Velmurugendran

The patient when just comes to the outpatient clinic emergency room. If he comes within the three hours, then we do a CT scan find out there is no hemorrhage; if possible do an MRI, spot the infarction and then we thrombolyzed these patients.

Dr.Kunal Jhaveri

Sir during the first three hours when the patient will come to the hospital in the emergency then you will give that.

Dr. Velmurugendran

We will try do that as early as possible. If we can do it in the first hour, it will be much more useful, but as soon as the patient comes if the emergency room is alerted, they can straight away go to the MRI room where the MRI scan can be done or if the MRI is not available, a CT scan can be done and then as the patient is being brought they can be given thrombolytic therapy.

Dr.Kunal Jhaveri

With the treatment of thrombolytic therapy, you must have found the as per ASC, the major side effect is the (6.00) intracranial hemorrhage. So have you found this kind of any side effects during your practice and how you have tackled this kind of the conditions?

Dr. Velmurugendran

No, intracranial hemorrhage can occur, but then is not all that common.

Dr.Kunal Jhaveri

Post stroke after treating the acute condition of the stroke, what kind of rehabilitation activity that you will take place to survive with better morbidity of the patients?

Dr. Velmurugendran

Then we will have to prevent the patient from the secondary stroke. Secondary prevention is very important. Depending on the patient, we will have to do that. Suppose if the patient has got an arterial narrowing, probably we will put them on antiplatelets to start the dual antiplatelets with clopidogrel, aspirin and later on make single drug along with statins. A high-dose of statin is initially indicated and later on a small dose can be given. If they have irregularity of heart, I think drug of choice will be anticoagulation (7.00) either with the conventional once or the NOAC.

Dr.Kunal Jhaveri

Surely, it is highly suggested. Based on your vast experience, we just need five or six important take points that we want to delivery to the patients or to delivery to the physician level regarding secondary attack of stroke. The patient has already developed a stroke then how will you go to prevent recurrent attack of stroke and what kind of rehabilitation therapy you should give them?

Dr. Velmurugendran

From day one, we will have to start the patient on physiotherapy that is must and then these patients who already had stroke will always have brain edema that has got to be reduced by adequate anti-edema medications like mannitol and if necessary we will have to decompress the patient if the infarction is large. Surgical decompression has got to be done. These are all the immediate things that we have to do. But secondary prevention of stroke depends on the patient’s heart rate and the echocardiogram of the heart. If the echocardiogram shows a blood clot (8.00), probably we will use anticoagulant therapy. If the echocardiogram shows irregularity of the heart, we have to monitor continuously. If there is an atrial fibrillation, we will have to correct the rhythm as well as give anticoagulation therapy simultaneously to prevent further strokes.

Dr.Kunal Jhaveri

Sir this is just a last question, in atrial fibrillation definitely there are two kinds of condition whether it is valvular or structural abnormality and there is a nonvalvular atrial fibrillation, so when the patient will come with the development of stroke then what kind of major patients you find with atrial fibrillation, whether it is valvular or nonvalvular and do you have any different regime for the treatment of both these conditions?

Dr. Velmurugendran

Yes, younger patients usually have the valvular type of atrial fibrillation and they have got to be corrected; probably you will have to look the correction of the valvular defect itself probably by replacing the valve. Whereas the nonvalvular more common (9.00) particularly after the age of 60, much more common and then they have to be anticoagulated or put on NOAC depending on the situation. I will prefer NOAC for the fact that they do not have to be continuously monitored and the food habits may not be changed. For example for South Indian, the most important food is vegetarian food and they will depend on green leaves which cannot be administrated to the patients who are on the conventional anticoagulants. Further, the conventional anticoagulants have to be continuously monitored and you note to have a reliable lab. The patient has got to the same lab then only the results will be correct. Because they to go a lab which is uncertain, then the values may vary. If they go to different labs, again the values may vary. So the patients who are coming from outstation have to come to the city, go to the same laboratory which is reliable and get it done. It is very cumbersome to do that, it is point number one. (10.00) I have already spoken about the diet. Dietary reason is again very strict. Thirdly the conventional anticoagulants will have side reactions with other drugs. So the newer anticoagulants do not have such problems. You do not have to monitor them continuously and then you do not have to worry about the diet and thirdly if the patient has gone to be taken up a surgery for some other reason – for example a person who comes with acute appendicitis probably will have to wait for three days, administer vitamin K and then we will have to take up the patient. If necessary, we will have to infuse fresh frozen plasma to negativate the activation of the conventional anticoagulant and then take up the surgery. Where as the newer anticoagulant, its action is only for 24 hours so we can stop the drug, (11.00) we can take the patient next day. The point is the complications like hemorrhages, particularly I am worried about the intracerebral hemorrhage which is much more common with the conventional anticoagulants compared to the newer coagulants. That way it will be useful. If we take the newer anticoagulants that are available, dabigatran and we have to got the apixaban and rivaroxaban. Rivaroxaban has got one slight advantage, single dose per day is enough. So the compliance will be better with the rivaroxaban. So I will prefer that to other drugs. The problem is that the cost factor, if you look at the total cost factor like doing the blood tests, etc., this is comparably equal, may be it got slightly costlier than other things, but then other cumbersome things like do not take this food, that food, etc. and drug reactions. (12.00) When we compare to that, these drugs are definitely far superior to the older drugs.

Dr.Kunal Jhaveri

Definitely Dr. Velmurugendran : has suggested very well that atrial fibrillation is a common disorder, but as a neurology perspective definitely the patient who has already developed a stroke and then come to the physician retrospectively he will found that this patient has already developed the atrial fibrillation. Regarding the management of the stroke as compared to the vitamin K antagonist and the newer oral anticoagulants, he has mentioned very in detail that one by one all the challenges of the vitamin K one antagonist like the food, drug interactions, most important INR monitoring, side effects like intracerebral hemorrhage and the compliance also. In the NOACs part, he has also very mentioned that all three NOACs more or less they are very equal and they are much effective and safer than the vitamin K. If we talk about the compliance point of view, the once daily dosage of rivaroxaban can have little bit upper hand as compared to the other NOACs. (13.00) Thanks a lot sir for providing your time and your valuable opinions, so definitely it will help us also to physicians and the patients to increase the awareness and more appropriate treatment for the management.

Dr. Velmurugendran

Thank you very much, I deeply appreciate your enthusiasm in propagating this information.

Dr.Kunal Jhaveri

Thank you sir.

Dr. Velmurugendran

Thank you very much.