Senior Interventional Cardiologist
</b> So sir if we talk about especially the prevention part of cardiovascular segment. So now a days there is a concept that the prevention is always better than cure and now it is very aggressive that from a physician prospective as well as from the different kind of pharmaceutical companies are also promoting this kind of the prevention concept. So regarding this prevention of cardiovascular disease what is your opinion on this particular segment sir.
</b>If you seen in Cardiology, if you see the way acute anterior myocardial infarctions have changed. If you see over the last 30 years the acute anterior myocardial infarction numbers have plummeted in the west. In India and China it is increasing, but even over a period of 10 years we expect these numbers to plummet. So in terms of cardiovascular disease, acute myocardial infarction and chronic stable angina all these diseases are going to plummet. If there are any two segments which is going to grow over the next decade or so, is two conditions, one is atrial fibrillation (1
</b> So it is very well said the atrial fibrillation and chronic heart failure both are now it is next era what we can say, last era what we can say was cardiovascular disorders, metabolic disorders like diabetes, but now the recent researches and even guidelines are also focusing on these two conditions regarding atrial fibrillation and heart failure. Now if we talk about the atrial fibrillation and its prevention, global incidence rate if we are talking it is about 1.8 to 2%. So it seems to be under detected and that is why definitely even all the governments are also now proposing this kind of awareness regarding atrial fibrillation. So what is your opinion on this particularly disease, that how can we increase the more and more incidence of it.
</b>See this whole concept of incidence is very frivolous. You know when you are in school you are taught one proverb (3
</b> So whatever number is there actually is not the actual number.
</b>It is just like this. I will put it in simple words. If I open my eyes at 10 o’clock in the morning and says sun rises in the morning, it is something like that.
</b> That is very well said. If we talk regarding atrial fibrillation and its complication, the stroke is one of the major complication when there is atrial fibrillation. You also said that when the stroke is happening then you have to go the retrospective to find out the underlying causes of atrial fibrillation. But now even the data is also saying that even when the patient is diagnosed with atrial fibrillation, there is no aggression is also seen in the physicians level to treat the patient (6
</b>The thing is very simple. At any point of time, any therapy, there are three issues involved. One is called the cost benefit ratio, second is called the risk benefit ratio, and the final thing is cost-risk benefit. So when it comes to atrial fibrillation, the biggest challenge faced by a physician is when you tell the patient that the risk of bleeding or the risk of treatment is almost parallel to the risk of benefit. When you put people on a warfarin therapy or things like that tell me how many patients would be convinced. Forget about the cost, cost comes later into the equation. You start off telling the patients that you have a problem, I will give you a treatment, this treatment may prevent the problem but may create another problem and may not still prevent the problem. If you make such a statement tell me (7
</b> That is definitely, it is the real world kind of scenario is of now in India as well. So if we talk about the management part of a stroke, definitely primary prevention as well as secondary prevention, various anti-thrombotics are available since aspirin, warfarin now the newer generation has also raised out. So you have passed with all the phase of these all three drugs. What you have found the advantage and also the challenges with older versus newer generation.
</b>See if you forget about NOACs, if you discuss Pharmacology in general, like this has lot of analogy to the gliptins in the market also. 25 years back when I joined medical college the concept was for more powerful and powerful drugs.
</b>Okay, so if tablet A is having this much effect and tablet B is having double the effect (9
</b> So definitely the newer generation oral anticoagulants they have some advantages as compared to the challenges of the vitamin K antagonists. Now if we go deep inside to the NOACs part, as of now in India the rivaroxaban, dabigatran and Apixaban, these three drugs are available. So how you will customize your patient according to the drug (11
</b>See I know I should not compare this to real life, but in real life also very often we have a concept called as first come first sell basis.
</b>Okay, so if you go back to our experience with NOACs, the experience with NOACs is almost like five to six years now. So, obviously since dabigatran was the first drug to be launched. So we had huge experience with the dabigatran like I can confidently say that more than 400 to 500 patients of mine are on dabigatran, so that is a huge number when you compare with other NOACs. So definitely dabigatran has a huge lead over all the drugs simply because they are first to hit the market.
</b>So that advantage with the dabigatran will persist at least for the next five to six years if I am not wrong. (12
</b>I would not say that rocket AF proved that rivaroxaban is superior to warfarin but at least when it comes to the safety data I think the safety data of rivaroxaban is very good and I feel the big clenching point about the rivaroxaban has been its safety with respect to myocardial infarction. So what happens is at the end of the day I am a cardiologist, so my bread, butter and jam everything revolves around (14
</b>But if you see the data on IHD the only drug which shows a real good benefit in terms of risk reduction and mortality and all those issues (15
</b> Surely, definitely sir has given very in detail description regarding the practical challenges as well that atrial fibrillation definitely as of now whatever the number is, that totally may be under detected. So there is no assurance regarding that. Because sir has said very clearly when we open eyes then definitely what we can see that is our belief. So, that is why its accurate history and accurate incidence rate to find out regarding atrial fibrillation is very very difficult task. Second thing what he told regarding older oral anticoagulants regarding the VKAs. They have very practical challenges like the monitoring and drug-to-drug interaction and to convince the patients regarding that is also very difficult task. In depth what we have discussed regarding NOACs, newer generation oral anticoagulants, that is from the first drug like dabigatran, rivaroxaban and followed by apixaban and how we can utilize each and (18.00) every drug in utilization of the patient’s treatment is very well discussed. So with this note