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Drugs in Atrial Fibrillation: Old and new

Vitamin K Antagonists have been the gold standard because of their efficacy, availability and cost effectiveness but the New Anticoagulants have a bright future

Dr. PB Jayagopal

Senior Consultant Cardiologist, Chairman

Lakshmi Hospital, Kerala


Dr. PB Jayagopal from Lakshmi Hospital, Kerala performs on Vitamin K Antagonists have been the gold standard because of their efficacy, availability and cost effectiveness but the New Anticoagulants have a bright future.

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Dr.Kunal Jhaveri

</b>We are going to discuss regarding atrial fibrillation. As you know sir, the atrial fibrillation is one of the commonest arrhythmic disorder even globally as well as in India, but if you find about incidence rate of atrial fibrillation it seems little bit to be unmatched as compared to the currently what the patients are coming in OPD and in your practice as well. So sir what is your take on this particular concern regarding the incidence of atrial fibrillation that whether the whatever currently reportedly globally it is approximately 2% whether it is actual or it may be under detected or what is the status in India, sir?


Dr. Jayagopal

</b>Well, this is a disease mostly in the aging population, so though we have statistics from the western part of the world where it is close to about 1 to 2%, India, we really do not have a documented data about the incidence of atrial fibrillation. In fact we are actually looking into study from the cardiology society of India, Kerala chapter. 01


Dr.Kunal Jhaveri

</b>So, definitely sir, you have raised a point regarding the aging population, as per one of the WHO survey by the 2040, the Indian population must be crossing almost around more than 35% when the age will be more than 65 years of age, so definitely this kind of disease where age is one of the important factor, we should have an earlier and on-time diagnosis before it is happening. 02


Dr. Jayagopal

</b>Well, if you look at the effluent population, no doubt I think most of the people would have a master checkup or let us say at least an EKG done, so that scenario, that subset of the population definitely would be diagnosed, but then the population at large when you talk about a country like India where you know the mass majority do not even have an access to primary health care, it is indeed difficult to screen them, but then I think over a period of time, for example, at least we have made tremendous progress in Kerala. I am certain that you know, most of the people whether they are rich or poor they at least from the cardiac perspective they get ample opportunities for detection and treatment. So I think in the overall context, I think over a period of time there has to be better screening methods, at least an EKG for someone above the age of 03


Dr.Kunal Jhaveri

</b>Definitely, it is very nice thought from your side that regarding we can have one center of the ECG database that from physicians you can collect ECG and they can send you on WhatsApp is one of best technology as well.


Dr. Jayagopal

</b>No not even WhatsApp, I think from a patients perspective they can have an app which is downloaded. See, no one ever felt that WhatsApp could be so popular, today see even the least educated person gets used to using a WhatsApp, so I am sure this could be used for the help of the medical community at large.


Dr.Kunal Jhaveri

</b>Definitely, regarding management part, if you talk about the atrial fibrillation, definitely rate and rhythm control remains the first priority to treat the atrial fibrillation, but if we talk about the complication of atrial fibrillation, as we know that when the patient has confirmed atrial fibrillation diagnosis then there is five times higher chance of risk of development of stroke. So regarding this particular stroke complication prevention, as of now the conventional management what we were using the aspirin or either oral anticoagulants 05


Dr. Jayagopal

</b>Well, it is the test of time, that the first thing that I want to convey and it is a cheap drug, both aspirin as well as warfarin, but then I really cannot give you the statistics where what percentage of patients with atrial fibrillation when they really deserve this molecule whether what percentage around this medications, but then overall I think we are all scared about the bleeding tendency with warfarin, so until and unless we have a proper laboratory measure to really have a very standardized blood test which is difficult in most of the centers, even in the best centers also, sometimes it is problem, so that is one of the major limitations and so mostly what happens in the Indian context, I think, the physicians tend to probably under correct the anticoagulant level so that you know you do not have the bad complication of a bleeding tendency, 06


Dr.Kunal Jhaveri

</b>So sir, have you found any real kind of challenge with this kind of use of the drugs in AF patient that you have given the drugs to the patient and then maybe long term followup is not there and when the patient will come then INR level may be disrupted, so have you found this kind of challenges?


Dr. Jayagopal

</b>This is a problem when you have a really very elderly patient where there is no one to take care of the patient and they cannot really schedule visit for frequent lab tests, those are the group of patients where you know you sometimes end up seeing them with a very high INR and they keep on taking this medicines and then of course 07


Dr.Kunal Jhaveri

</b>Definitely, regarding this challenge is there, but definitely proper awareness and counseling of patients definitely will help and reduce all the kind of challenges also very well. Now, if we talk about the newer generation or oral anticoagulants which has recently just within the last four or five years it has been launched in India as well, so what is your take on on this particular group of the drugs, where the rivaroxaban, dabigatran, and apixaban, now they are available in India and they have proven that they are at least non inferior to the VKAs and safer side as compared to the warfarin as well, so how do you opine on?


Dr. Jayagopal

</b>Well, it is a welcome change, no doubt you know 08


Dr.Kunal Jhaveri

</b>You have very well said that definitely MI is the part of some major concern with dabigatran but still it is nonsignificant so we cannot say anything about this particular side effects on this particular drug. 10


Dr. Jayagopal

</b>Well, in ACS situation I would definitely avoid dabigatran because with the kind of negative data that we have, that is one thing for sure, but apart from that I think the dabigatran is an advantage where you know you can even use it in a dosage of 75 mg twice daily in renal impaired patients. So there is an advantage like that but otherwise I think in a routine practice particularly for atrial fibrillation, really it does not make much of a difference.


Dr.Kunal Jhaveri

</b>Sir, last question is regarding the stroke prevention in AF. It remains one of the lifelong therapy. So even the guidelines also suggest that once patient is diagnosed with AF then at least oral anticoagulant should be for lifetime to prevent a stroke 11


Dr. Jayagopal

</b>Let me put a counter question to you. Well, we have the problem even with a post ACS patient with just a simple aspirin and clopidogrel. People do not keep taking this. Aspirin is supposed to be life long and we find lot of people coming back without any medications or stopped medication. From that prospective, I think it is just the same. I mean, nobody wants drug to be taken for a longer time, but then warfarin apart from the kind of, if patient is stable, lets say somebody is stable on 5 mg of warfarin and they do well without much bleeding tendency then there is no major 12


Dr.Kunal Jhaveri

</b>So definitely your messages sir well we have taken. 13


Dr. Jayagopal

</b>First thing is you need to assess whether the patient really needs an oral anticoagulant. You know you have different criteria the CHADVASc score and so on and so forth, and if you are convinced that the score is there and then you need to put a patient on an oral anticoagulant that is the way to go about, we all know for sure and then you have the different choices. The advantage of this agent is that you know you have advantage where you do not have to monitor the blood test very frequently and renal impaired patients, in fact I was reading the literature these days. Warfarin is also known to impact the renal function over a period of time. So perhaps that point of view I think all of the newer agents are effective and dabigatran also in a renal impaired patient could be used at a lower doses and the newer molecules like rivaroxaban, apixaban 1400 again definitely has a place. There is no drug interaction, no food interaction, so that is I think one of the key thing that this could be used but then I think it is important that this is lifelong remedy and one has to really look into the financial status of the patient as well. One major area where I would feel this is useful is because when you start using an oral anticoagulant, particularly when there is a real indication you always overlap it with heparin or low molecular weight heparin, which is not required for this molecule, it starts acting straight away. So that is one major advantage for the physicians where they just start it as an outpatient basis, they can easily monitor the patient. But then a word of caution, because when these patients come to you with a bleeding tendency, you really have to tackle this because some of this are not really dialyzable but then sometimes you know you have to give a fresh frozen plasma and then really take care of this problem and then I think we still have to wait for the newer antidotes to come into the market for you to feel more comfortable about this. It is just as a monoclonal antibody has to really come into the market and should be easily available. 15


Dr.Kunal Jhaveri

</b>So definitely sir has said very well that atrial fibrillation is a major concern of the society and its diagnosis and awareness is also one of the major part that we have to focus on that and regarding we talk about the management VKAs are still the goal standard because of good efficacy and at the cheaper they are available and the NOACs has a bright future as compared to the VKA but still apart from INR monitoring if companies are focusing on cost then definitely it could be a next future of this particular atrial fibrillation treatment. So sir thanks a lot on behalf of us and definitely we are thankful for your providing your time and your valuable opinions.



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