Atrial Fibrillation: Detection and Drugs

Frequent INR monitoring no longer required with New Oral Anticoagulants
Dr. Sarthak Sahu

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Dr.Kunal Jhaveri

Today we have Dr. Sarthak Sahu who has post graduated in diploma clinical cardiology and currently serving as an associate consultant in MS Ramaiah Narayan Hospital at Bangalore. So, sir it is a warm welcome for this particular show at the revolution talk. Today, we are going to discuss regarding the atrial fibrillation which is the commonest arrhythmic disorder in the cardiovascular therapeutic area. What are the challenges that you will find during your AF diagnosis and screening part and how the treatment can be better on with the older oral anticoagulants to the newer generation of oral anti coagulants. So, sir if we talk about that regarding atrial fibrillation, currently the incidence rate is around 1.8 to 2%, still it seems that it is under detected disease. So, what is your take on this particular concern, whether it is under detected and if it is yes, then why.

Dr. Sarthak Sahu

Atrial fibrillation in a lot of cases is paroxysm (01:00). So when it is paroxysmal atrial fibrillation, a lot of the times patient would be coming or may not come to the hospital. They say that they have a little bit of palpitation or no symptoms at all, till it worsens. So lot of the times they come either once the disease progresses or else they have complications secondary to atrial fibrillation. That is how they land up in the hospital. As a result of which it is under detected unless the complications are there.

Dr.Kunal Jhaveri

Regarding under detection, can we have some advanced screening program like opportunistic surveying, even ASC guidelines also suggested that in some group of patients when there is age more than 65 you should have some opportunistic surveying so that you can have on time diagnosis of atrial fibrillation.

Dr. Sarthak Sahu

First of all awareness amongst the community should increase that is very important and palpitation per se, occasional palpitation, patients when they suggest (02:00) that they are having palpitations then they must be evaluated for possibility of paroxysmal atrial fibrillation that is very important and you can go for, if the risk factors are there and if they show certain pictures like dilated left atrium, so in such cases the chances are much more. So you can go for an initial echo evaluation, go for a 24-hour Holter monitoring in patients who are complaining of palpitation, giddiness.

Dr.Kunal Jhaveri

So, definitely if we talk about the AF complication regarding the management part, rate and rhythm control is very very important. That is why the drugs like beta blocker as anti arrhythmic can be used. But now the major focus is that its complication, the stroke. As per the data, there is a 5 times higher chance of stroke in atrial fibrillation. (03:00) So regarding the stroke prevention, what kind of treatment therapy you will be preparing, because a number of drugs have been evolved from the aspirin, then the warfarin, vitamin K antagonist, now the newer generation is also available. So how you have evaluated your treatment also as of now.

Dr. Sarthak Sahu

See first of all, when you are talking about treatment of atrial fibrillation, most of the times we land up treating paroxysmal atrial fibrillation that have been there for quite a few months yes, which is difficult if you go for rhythm control it becomes very difficult, you may nor may not be successful on long term basis. So, rate control is the number one, but along with that oral anti coagulation is very important which is sometimes missed out. So when you evaluate and manage such patients, you have to go for the risk scoring analysis whichever risk scoring analysis you prefer CHADS-VASc, a lot of pamphlets are also available. So, you have to go for the risk scorning analysis and once you go for the risk scorning analysis, (04:00) if the patient is in the higher risk category, start the patient on oral anti coagulant, according to the present available literature, I would prefer NOAC, particularly if the patient is not having a rheumatic heart disease, nonvalvular atrial fibrillation, definitely I would prefer a NOAC. That is the number one choice. Valvular heart disease with atrial fibrillation, yes we do not have enough data to suggest then in that case I would go for a VKA, Vitamin K antagonist. As far as the anti coagulation. Along with that beta blockers, or Diltiazem, Verapamil either of them we should go.

Dr.Kunal Jhaveri

You said about the NOAC newer oral anti coagulants. So as of now in India, the current is Rivaroxaban, Dabigatran and Apixaban, these three drugs are available. So what is your preferable choice, I cannot say your preferable choice but how you will select the drug for treating the stroke prevention atrial fibrillation (05:00). How will you customize the treatment?

Dr. Sarthak Sahu

As a class they are better compared to your VKA when you are particularly looking from the prospective of the nonvalvular atrial fibrillation. So the effect as such is more or less similar. Now what you are going to look here is patient compliance. So when you look at patient compliance once a day dosage is better than twice daily dosages. So in that scenario Rivaroxaban, and Apixaban they score over Dabigatran because it has twice daily dosage module. So now the choice comes between two drugs Rivaroxaban and Apixaban. Till date the number of studies that have been done, they prove in certain specific scenarios Rivaroxaban to be better. You know the studies are there with Rivaroxaban compared to Apixaban. So, when the probability for the drug to have lesser side (06:00) effect is there or lets say renal impairment scenario, moderate renal impairment scenario or severe renal impairment scenario, particularly up till moderate. In severe renal impairment we would not like to prescribe. Till moderate renal impairment scenario Rivaroxaban is doing better. So we are safer with Rivaroxaban. So number one option would be Rivaroxaban. Number two option Apixaban. Number three option Dabigatran. So, I would chose Rivaroxaban.

Dr.Kunal Jhaveri

So, it is very well said by Dr. Sarthak Sahu that regarding the atrial fibrillation definitely it is a major concern of the society and the detection rate is low because awareness is very very less in a patient prospective as well. As we have said also that the screening, opportunistic screening should be done as soon as possible when some kind of risk factors like dilated heart failure and hypertension.

Dr. Sarthak Sahu

Left atrium or else patient is coming repeatedly with history of lets say giddiness, (07:00) syncopal history is there, or palpitation history is there then we should evaluate such cases more seriously. We should not neglect it, we have to find the root once.

Dr.Kunal Jhaveri

So, this is the part. Now he has also mentioned regarding the management part that there are oral anti coagulants, older are the warafarin, vitamin K antagonist, their monitoring and issues are there. Dr. Sarthak Sahu: That is definitely there and particularly when you are giving NOAC you do not have to worry about the food intake, the timing of the drug, and drug to drug interactions all those things just go out of the window. So you are very safe. Once you start a NOAC you are safe. You do not need to give the detailed explanation to patients and frequent monitoring of INR is not necessary. See what we do is when we are giving Warfarin or Acitrom we check the INR we do an OPD reading and say the INR is lets say 2.2 in the OPD. What guarantee is that when the patient goes back home and after six days the INR is remaining 2.2 (08:00). Because it is varying on a daily basis. Today the patient has taken some spinach unknowingly INR would have fallen down to 1.8 to 1.7 with the same dosages. You really do not know and the INR values have to remain within the prescribed limit if you want to provide safety to the patient which we actually have not been able to address. We do get cases of CVA inspite of the patient taking the drug. Yes that way if you see it is better.

Dr.Kunal Jhaveri

So, that is a very practical point what you have raised regarding monitoring of INR and the food habits because Indians remain more or less vegetarians and the green leafy vegetable has also a significant food-drug interaction and you never know because the day to day followup of the patient is also not possible when he is discharged from a hospital that what is the INR level and that is why on that part NOACs are very safer because once we have given it remains there (09:00). Blindly the patient can remain on it until unless there is any significant or major side effect is visible. Regarding the selection of NOAC, also mentioned that patient’s preference and compliance is very very important, that once daily is always preferred than the twice daily regimen and also regarding that in some cases like renal failure and some impairment Rivaroxaban is a better option with the high risk of GI bleed and everything, the Apixaban can be a better option. So, thanks a lot, thanks a lot Dr. Sarthak for all your valuable comments regarding your opinions. It will be helpful for further medical fraternity.