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Today we have one of the very renowned interventional cardiologist, Dr. Nishith Chandra, who is a a director at Escorts Fortis Hospital at New Delhi.
Sir, it is a warm welcome participating in the show on the revolution talk. So sir, as a cardiovascular disease segment, you must be knowing that the prevention always now, considering we are also promoting that the prevention is always better than the cure for any kind of the disease, so now there is a concept of prevention of any kind of the cardiovascular disease like myocardial infarction, and atrial fibrillation, and prevention of stroke in atrial fibrillation, so there is various concept that is going on. So Sir, what is your key messages on this particular concept that how we can drive for the betterment of society in India.
As you have rightly pointed out, basic guts should be on prevention because we can not fleet, the treatment is very costly treatment and the morbidity and mortality is higher, so unless we prevent the disease right from its inception, we are not going to address this (01:00) huge burden of coronary vascular disease, arrhythmia, or atrial fibrillation. So, we have to start lifestyle changes right from the beginning to prevent the cardiac diseases.
As an interventional part, definitely you have many patients on the acute coronary syndrome and sometimes the stroke patients also comes in your practice, so these both are the very devastating conditions and they may impact the life of patients, so how you have observed that these were the conditions though it is not comparable, but if they are going to impact the life, then up to what level they can impact the life of the patients.
Actually, if you compare the acute coronary syndrome versus stroke, stroke is more debilitating and stroke is devastating for the family. A person in his youth becomes bedridden, he is not able to perform, he is not able to earn. While in acute coronary syndrome, you can revascularize the patient and he goes back to his work very fast. (02:00) So the livelihood lost in stroke is much more and impact more on the family economically than in acute coronary syndromes.
So, definitely the ACS, incidence rate is very, very high, but again the lifetime cost of the stroke is much, much higher than the active coronary syndrome.
The quality of life in stroke is worse than in the acute coronary syndrome.
So that is why in atrial fibrillation in which the stroke is one of the major complication you have found, regarding the stroke prevention atrial fibrillation that seems so far many drugs have been come around from starting aspirin, then vitamin K antagonist, and now the newer generation drug is also available, so what is your experience on this all three generation of the drugs if you start from the warfarin, then aspirin, and then Naox, what is your experience and how these drugs have changed your practice also in this particular sense.
Traditionally, when we treat (03:00) atrial fibrillation, we have two goals; one is rate and rhythm control and second most important is prevention of stroke. Now people die from atrial fibrillation not by any arrhythmia, but by stroke. If we leave this atrial fibrillation untreated, 3% to 4% of these people have stroke, so it is our duty to prevent this treatable causes of stroke, which is atrial fibrillation. And if you see the arrhythmias, in arrhythmias atrial fibrillation is the one of the commonest arrhythmias in population and as the age advances as the risk factors high blood pressures, diabetes, and obesity increases, the incidence of atrial fibrillation and so the incidence of stroke increases in the population.
So if you tell about the treatment management part, (04:00) so you must have used many times the vitamin K antagonist like warfarin or Acitrom, still they are goal standard agents but they very definitely useful drugs but how smoothly that this drug can be used?
Ya, so far majority of population of atrial fibrillation depends upon vitamin K antagonists like Warfarin, Acitrom, but the biggest draw back of them is very low narrow therapeutic index or window, so the toxicity levels develop very fast if you do not measure the INR values. The INR value has to be kept in a very narrow window of between 2 and 3. If the INR goes below 2, then they are chances of ischemic stroke and if it goes beyond 3, then the chances of bleeding are higher. To maintain that INR between 2 to 3, (05:00) the person has to go repeated INR levels, which in our country is very, very difficult. People are from remote areas, villages, the INR facilities are not available and there are lot of individual variabilities from lab to lab. Same sample given at two different labs will give us different INR values, so person would be confused what to do with the Warfarin doses plus this vitamin K antagonists, they have lot of interactions with food. When we prescribe these, we impose lot of restrictions on the diet of the patient like all vitamin K containing food should be avoided like green leafy vegetables, citrus fruits which makes the life of patient or the diet of the patient very unpalatable. So that is the reason these vitamin K antagonists have, there is a need for a newer alternative (06:00) which is safer, which does not require INR monitoring, and which has less interactions with the diet as well as other drugs.
So Sir, as rightly maintained that older generation molecules are there, definitely they are goal standard, but now there is a need of their improvement in the particular group of the drugs as well. So Sir, you have talked about the newer generation of oral anticoagulants NOAC group. So these drugs are available in India almost since last 5 to 6 years. As of now, the dabigatran, rivaroxaban, and apixaban one by one they were launched in India also as well, so what is your experience with these all three molecules?
Ya, it stared after relied data when the dabigatran was launched. Now it was launching two doses 110 and 150, but the disadvantage of dabigatran was that it had to be given twice daily doses, then it came to be very, very expensive, so whenever the number of tablets are increasing per day (07:00) by the patient, then the compliance go down, so our aim as a clinician is to reduce the number of tablets consumed by the patient per day. That is how the concept of polypill was also launched. So, if we have NOAC which is single daily dose and that scores over a double daily dose of NOAC that is where the dabigatran scored less than other newer anticoagulants which are single dose.
This is the last one that as an interventional cardiologist, definitely the ACS is always the maximum number of the patients that you are going to treat but when that dual morbidity coming, for example ACS along with atrial fibrillation and you have to stop the recurrent MI events and also you have to stop the stroke in that particular AF patients, so how will you go ahead along with DAB that is used of (08:00) oral anticoagulants, so how will you manage this kind of patients.
Now, this is a very good question, in fact because we got lot of patients who require stenting as well as they are in atrial fibrillation. Now, we have to prevent the ischemic episode and we have to balance the increased risk of bleeding also. Now, we cannot stop the dual antiplatelet, thienopyridines, and aspirin but in addition to prevent the stroke because thienopyridines alone cannot prevent the stroke from atrial fibrillation, so the only NOAC which is approved and proven is rivaroxaban while dabigatran when added to dual antiplatelets or apixaban when added to dual antiplatelets increase the bleeding, while rivaroxaban in a single daily dose has proven that if you add to the dual antiplatelets then it does not increase the bleeding, but it reduces the stroke risk. So, this rivaroxaban in a single dose can be (09:00) safely combined with dual antiplatelets to prevent stroke in patients who are undergoing PCI.
Okay, so Dr. Chandra said very well and very brisk and very practical aspects regarding the stroke prevention atrial fibrillation. AF definitely is one of the commonest arrhythmic disorders but the complication of stroke is always worse as compared to the acute coronary syndrome because it can impact the patient for a lifetime with disabilities and as the consideration that the management of the stroke prevention in AF from the oral anticoagulants with vitamin K antagonists are available but they have some practical issues like INR monitoring and drug-on-drug interaction and poor compliance for the longer time of management and in compare of that the NOAC can provide solution on these three particular points and as interventional cardiologist, definitely when the ACS and AF when these two diseases come in single patient then (10:00) how we can go ahead with rivaroxaban along with DABT, so that is a very valuable suggestion for me. So with this notes, we are ending our discussion. Thanks a lot sir for providing your valuable opinions.