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Stroke prevention in Atrial Fibrillation

Ageing and comorbidities like hypertension, diabetes and obesity have increased the incidence of non-valvular Atrial Fibrillation

Dr. Rakesh Gupta

Director and Chief Cardiologist,

JROP, Delhi,


“The Electrocardiogram is the single most important and easily available test for the diagnosis of atrial fibrillation. The absence of T waves in the ECG is characteristic of atrial fibrillation,” says Dr. Rakesh Gupta, Jaslok Hospital, New Delhi. “Atrial Fibrillation is of two types, valvular and non-valvular. In the last few years, factors like ageing, obesity, hypertension, diabetes, obstructive sleep apnea and hypothyroidism have given rise to non-valvular atrial fibrillation.” “While most risk factors can be controlled, ageing is inevitable. Atrial fibrillation due to old age can be treated with conventional or newer anticoagulants.” “Although time tested and effective, Vitamin K Antagonist has a high incidence of bleeding due to unstable INR ratings, making its compliance low. Rivaroxaban, in this context has proven to be a very good drug that doesn’t need regular INR monitoring.” “Compliance, cost and INR levels are three important criteria in prescribing an anticoagulant, which is a life-long therapy.”

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Dr.Kunal Jhaveri

</b>Today we have one of the renowned clinical and non-invasive cardiologist, Dr. Rakesh Gupta who is from Jaslok Hospital based in New Delhi. Sir it is a warm welcome for the Revolution talk. So, sir, as you know that in arrhythmic disorders, arrhythmia is one of the commonest disease having the incidences of around 30-33%. So you have such a vast experience and so in your routine practice how do you look at atrial fibrillation from the diagnosis point of view.


Dr. Rakesh Gupta

</b>If I have to look for atrial fibrillation for a diagnosis practice, take my words, single simple most important test is electrocardiogram, practically available every nook and corner of our country which can be done even by a basic medical physician who can diagnose atrial fibrillation (01


Dr.Kunal Jhaveri

</b>Perfect, so I think it is not so much difficult. ECG is available everywhere, now in the corner of India also the ECG machines and even the physicians are also now well aware of this very particular plan.


Dr. Rakesh Gupta

</b>Very well trained and aware of it. <br> Dr.Kunal Jhaveri


Dr. Rakesh Gupta

</b>Well, India has been a largest country (02


Dr.Kunal Jhaveri

</b>So definitely sir you have mentioned very well the non-valvular and valvular two parts of atrial fibrillation and now because of awareness of disease and with long age and multiple comorbid conditions, non-valvular atrial fibrillation incidences are also increasing now by leaps and bounds. So regarding the non-valvular atrial fibrillation, as for the data, one of the commonest complication is the stroke. So, how do you find that when the patient has non-valvular atrial fibrillation and the chances of developing stroke with various risk factors. What is your experience?


Dr. Rakesh Gupta

</b>Certainly if a person of all these comorbid (04


Dr.Kunal Jhaveri

</b>Okay, so definitely you have mentioned that regarding the management part the control of atrial fibrillation is very very required. So the first chance what you will take to revert the atrial fibrillation to the normal sinus rhythm and meanwhile you should start the oral anticoagulants whether, initially there was vitamin K antagonist, now the newer generation of oral anticoagulants are also available. But sometimes in your practice you must have also found that you have tried very aggressively and tried to revert the patient to the normal sinus rhythm (06


Dr. Rakesh Gupta

</b>In fact, if you look at the true scenarios of stroke prevention in atrial fibrillation, anybody who is more than 65 years of age we have to give them anticoagulants. So if somebody does not prescribe it is not being an ethical practice.


Dr.Kunal Jhaveri

</b>So in this condition, where the patient is not reverting to the normal sinus rhythm and still you have to do the treatment for the stroke prevention in atrial fibrillation, what could be your management.


Dr. Rakesh Gupta

</b>Well, till date, like I can say that we have been using time tested vitamin K antagonists from a long time. They are very good, time tested, lot of data which is available on them but the most important thing is we have to maintain their INR (07


Dr.Kunal Jhaveri

</b>So it is a very practical point that you have raised that oral drug available, they are effective but monitoring of INR is a biggest issue in India and the new oral anticoagulant may be the best solution. If they are the best solution for the prevention of stroke and atrial fibrillation. So sir in India, since the last five to six years, different types of new oral anticoagulants are available like dabigatran, rivaroxaban and apixaban. You must have used all kind of drugs in your current practice. What is your experience with these different drugs (09


Dr. Rakesh Gupta

</b>Look while choosing a new generation oral anticoagulants drugs I have to look for a couple of things. The first and foremost thing is the compliance of a patient in the form like how many tablets he has to take one day. Second the cost of the drug, what is the average cost for the drug for the patient. Third, do I have to really look for the INR in this subset of population. So these three criterias will make lot of difference because they have to take this drug for lifelong. If I am looking in an aging person, who is in atrial fibrillation it is not going to be a drug for one day. I say drug to eternity for him. So all these factors make lot of difference and looking at all these three drugs which you have quoted a couple of minutes back, I feel like couple of drugs which have really made mark is, one of them is rivaroxaban (10


Dr.Kunal Jhaveri

</b>So Dr. Gupta has said very very well and in detail and there is actual practical scenario in Indian condition regarding the atrial fibrillation and the stroke prevention. Older generation molecules are effective, they are good but the INR monitoring is not possible up to mark in corner of each and every part of India and to replace or to give better solution for them new oral anticoagulation is better solution but again for better compliance and lifelong treatment the cost is also one of the biggest factor, so that is also one of the considering factor when you are using the new oral anticoagulant in atrial fibrillation patients. So with this note, sir, we are ending our discussion and thanks a lot for your valuable comments and expert opinion.


Dr. Rakesh Gupta

</b>Thank you very much and we look forward to have something more.



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