Mother Hospital, Kerala
Today, we have one of the senior doctor Dr. Geevar Zachariah from Thrissur who is currently convener of preventive cardiology from the Cardiology Society of India and also Chairman of Mother Heart Care Institute from Thrissur. Sir, it is a warm welcome for this particular revolution talk of atrial fibrillation. Before that, I have just seen that there is a preventive council of cardiology society of India, so that may be the concept of prevention of disease in cardiovascular therapeutic area. So definitely it is a very exciting term. Sir, can you express what you are doing in this particular program and how it can be better for the society of the India sir.
We all know that prevention is better than treatment of established coronary artery disease. Because coronary artery disease is increasing all over India and Indians seem to have special revolution to develop coronary artery disease and heart attacks. The reason why Indians have a high prevalence (01:00) of coronary artery disease is mainly because of increased risk factors which are poorly managed. The risk factors for coronary artery disease are high blood pressure, diabetes, high cholesterol and smoking and then physical inactivity and obesity and psychological stress. All these are poorly managed among Indians and that is the reason why Indians have high prevalence of coronary artery disease and secondly even if they have coronary artery disease, they are not well treated after the secondary prevention efforts are effective. There are efficient institutions where acute care is being provided all over India and new centers are coming yet. There are new centers for angioplasty and bypass surgery coming up in all over India, but the prevention is probably getting a back seat (2:00) with even after undergoing angioplasty or surgery, many people after one to two years down the line they do not follow the secondary prevention guidelines and that adds to the mortality due to coronary artery disease. So our effort as a preventive counsel is to rectify these mistakes. Because we are in days committed to the World Health Organization and World Heart Federation motto of 2025, reducing the coronary artery disease mortality by 25% by year 2025 and the emphasis by the World Health Organization and World Heart Federation is to address to all the risk factors but concentrate on improving hypertension control then prevention of smoking or smoking cessation and improving (3:00) secondary prevention. So, this we have been trying. We have conducted conferences. We have interacted with the Government and we are popularizing among the professional organizations and other nongovernment organizations.
Sir, this is regarding a preventive part for the patient’s prospective what is your step that how this concept will reach to the patient directly.
Patients need to be told that I think taking good care of the risk factors is important, for example high blood pressure, around 28-30% of adult Indians have high blood pressure; however, a large majority of these people are not aware that they have high blood pressure, in fact, in our study, which we did in Kerala, we found that only 30-40% of patients with hypertension are aware that they have high blood pressure. I think the scenario cannot be different in rest of India. Also, there are some limited studies from North India, Bombay, all showed the same things. People have high blood pressure 28-30% in the population, similar to in the west and other developing countries, same prevalence rate for hypertension, but there, the control rate that awareness rate is much better. In US, the awareness of high blood pressure knowing that they have high blood pressure is around 80%. Our awareness is 40-45%. Even if people are aware about their high blood pressure, they are not treated properly, the control of hypertension (5:00) is around 17% in India, while it is around 50% in the developed world, so there is huge gap between what is desirable and what you have now here in India. This is for high blood pressure and the smoking campaign is taking some affect. The government has committed to promote cessation by advertisements and other things and banning smoking in public, these things are working very well, but people who are already smoking the quitting rate is not very high. We are preventing the young people, may be we are preventing young people from starting smoking, but in our study in Kerala also same thing. The younger generation prevalence rate of smoking has come down (6:00), but the elderly population they continue to smoke and one reason why we thought they continued to smoke is because of the unfamiliarity of doctors to advise them properly how to stop smoking. Most doctors are not knowledgeable when it comes to the proper advice to stop smoking. Because they are already well defined behavioral therapy then drug therapy for cessation of smoking, established one but many doctors, I would say most doctors are not aware about this and they do not put this into practice when they treat a patient who smokes, that is the problem. Other areas also high blood pressure, high cholesterol, diabetes and physical inactivity. Promoting physical activity should be a priority area (7:00) but now the people are buying two wheelers like anything, road does not have pedestrian footpath in many areas and walking is a big risk in our heavily congested roads and the space available, public parks, they are now shrinking. So people do not have adequate opportunities for relaxation and physical activity. That is a collective combined effort is required, not only by the doctors has to recommend physical activity but also the government and local bodies should try to promote, the government is aware about this. That is why the special instructions and special white papers have been issued regarding the need for, when you plan a CT. for example in New Bombay, I am told that they have very wide footpaths and new cities (8:00) which are coming up it is possible, but the existing cities they are very congested now and physical activity is coming up.
So, definitely it is a very nice thought of that for prevention in cardiovascular disease in various segments like the myocardial infarction, diabetes and also the physical inactivity which is a very common now we can say because of the technology is available so widely, so worst part is people are becoming very, very lazy and they are depending on various kind of instruments. Sir, we have talked regarding the prevention, definitely as a consultant you must have seen many patient regarding the acute coronary syndrome, may be some patients on arrhythmic disorders like atrial fibrillation and you have heard that the stoke is one of the major complications of atrial fibrillation and ACS and stroke both are we can (9:00) say it is a top two factors which can have the highest mortality in worldwide also as well. So what is your take on that. If both diseases are there, though they are incomparable, but how they can impact the patient’s lifetime.
That is right because they are even though both are one is the atrial fibrillation and arrhythmic event and coronary artery disease involve the myocardium and the blood vessels; however, people with an acute coronary artery syndrome may have a left ventricular dysfunction, left atrial enlargement which predispose them to develop atrial fibrillation and secondly during a course of acute coronary artery syndrome, if they develop atrial fibrillation, the mortality is high and the chance of thromboembolic event is very high. So, I think this acute coronary syndrome and atrial fibrillation often coexist (10:00) and its treatment is very important because it is treatable. Atrial fibrillation can be controlled. The rate can be controlled. The thromboembolic events can be controlled and acute coronary syndrome and atrial fibrillation can be managed effectively if proper treatment is given at the right time.
So, definitely this prevention is very, very important for both the conditions. Even if because the stroke is a major complication and if we diagnosed the atrial fibrillation as soon as possible as you said it is treatable, so you can control the rate and rhythm and also you can prevent the stroke. So, this is just question is for you sir that for the management of stroke in atrial fibrillation, you must have heard about antithrombotics, the various generations of antithrombotics from aspirin, warfarin, now the newer generations are also available rivaroxaban, dabigatran and apixaban, so what is your take on, on this particular generation of treatment that you started aspirin and warfarin, now it is a newer generation what difference you find (11:00) and how it can be more and more better for the AF patients.
For atrial fibrillation patients of any patient, stroke is a very devastating complication. Because it causes a lot of disability and problems to the family and I think something which needed to be prevented. Atrial fibrillation certainly predisposes a patient to develop stroke and the chance of stroke in any patient with atrial fibrillation is very high. Previously we thought probably aspirin and other antiplatelet drugs will be effective in preventing thromboembolic complications after atrial fibrillation, but many studies have shown that, this is not enough. Aspirin and other antiplatelet drugs are not effective in preventing the stroke in atrial fibrillation. So the time tested and proven medication was vitamin K (12:00) antagonist, warfarin and other related compounds and they are proven to be very, very effective. The problem is the compliance, very unreliable drugs like oral anticoagulants. There are several problems because you need to check the prothrombin time periodically. How frequently you need to check is variable but mostly at least once in a month and there are some patients the prothrombin time is so variable that you need to check prothrombin time once in a week. Now this is a big problem. Our labs are not well standarized so that you people check the prothrombin time and get an INR value from one lab and then immediately they go and check another you get it (13:00) diagrammatically totally different, not even 20%, I have seen patients with INR value of 6.8 from one laboratory then another lab giving a value of 1.8. So such a huge difference is because of the methodological inaccuracies and different kids employed which are not well standarized. So there are a lot of issues and then patients. Patients sometimes you put on oral anticoagulants, vitamin K antagonist and then part of patients who seldom test for prothrombin time. I have seen patients who come back after six or eight months saying that they never bother to check prothrombin time. Either they are aware, but they thought that is not very important. So I think that almost all doctors and cardiologists and people treating these patients (14:00) with atrial fibrillation for prevention of stroke have been frustrated. There have been good results, but the bleeding complications, intracranial bleed and deaths occurred in life. I used to tell my patients before starting an oral anticoagulant even if they have atrial fibrillation, I will tell them if you do not have, I do not want you to die due to an intracranial hemorrhage which is a strong possibility when you are taking on oral anticoagulant. So, unless if you are not comfortable in checking your INR periodically better accept the risk of stroke rather than continue on vitamin K antagonist and many times I am right and I had to treat patients who come with intracranial bleed (15:00) or massive GI bleeding. So, one may be a solution which is emerged of the recent time is the newer oral anticoagulants. There are several molecules now that the newer oral anticoagulants. They are effective and there is no need to monitor these patients with periodic prothrombin time, which I find is a tremendous advantage for the patients. The problem there is about the comprehensive part because these drugs will have to be taken without fail. Advantage of vitamin K antagonist is if you stop the vitamin K antagonist, the effect does not disappear immediately, but this newer oral anticoagulants if you stop one day, the effect goes immediately (16:00) and then the risk of stroke returns and the cost factor. Because the chances of noncompliance is very high because the cost of the medication is also high. That I think is one factor, so I do not know how to solve this problem if more and more people have proper medical insurance, I think this problem would have been solved, but I think that trend is happening. People are aware about this and taking more medical insurance that is one way to go about it, but; however, I feel that considering the scenario if newer oral anticoagulants are available at a competitive price, as a doctor, I will prefer to use this agent rather than the conventional (17:00) oral anticoagulants because of difficult experience of controlling the INR in some patients.
Okay so I think Dr. Zachariah has given very in depth regarding the knowledge of first of all the prevention part of the cardiovascular disease because it is now very challenging that before this is happening how we can prevent the disease, so that mortality and morbidity benefit can have on the patients as well and regarding the stroke prevention and atrial fibrillation, very common and particular point he has raised regarding the prothrombin time monitoring and INR monitoring, this is a very critical situation when the patient is on older part. So, the newer generation molecule has that advantage which can increase the effect in the safer side also as well but also again the compliance is also there with the newer generation because of higher price as of now what is available there in India. Sir, thanks a lot.