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Dr.Kunal Jhaveri: As you know that if you talk about the atrial fibrillation, so definitely this disease is globally one of the prevalent disease having the incidence state of around 2% approximately, so what is your take on that, because still it seems that it is one of the under detected disease and you must have seen many patients with atrial fibrillation during your practice and during your clinical experience. So what is your take on that, what is the diagnosis rate, is that whether it is appropriate or it is underdeteted and how we can improve on this particular part as well.
Dr. Guru Prasad: Sure, the global prevalence of atrial fibrillation has been as you know, at least we have the data from U.S. and Europe, it is 2% they say and though we are large population in India but we do not have specific incidence and prevalence of atrial fibrillation but I must say now we have some West Burningham Cooperative Registry Data which says that (01:00) in this registry we have only 0.6% of atrial fibrillation, so but of course this is definitely not the true incidence or prevalence but as a cardiologist I must say definitely Indians have lot of atrial fibrillation which is truly really undetected, it is like a tip of iceberg what we see and patients come only when they are symptomatic, especially poor patients they come in the stage of complication. Definitely in India it is under detected and it is more prevalent than what is described in the literature and I can say because India, it is bit of under reporting is especially in relation to non-valvular atrial fibrillation is (02:00) because we have more of rheumatic atrial fibrillation. So usually at young age they seek medical advice because of rheumatic fever and then related complications and valvular disease and atrial fibrillation is a part of rheumatic valvular disease. So, non-rheumatic atrial fibrillation or non-valvular atrial fibrillation is truly under reported in India. I feel it is definitely more prevalent.
Dr.Kunal Jhaveri:So, sir as you mentioned very well that definitely in India the rheumatic condition is one of the prevalent condition from childhood and the patients are getting valvular deformity at later age on. So currently what we have also seen that there are so many screening studies are also going to happen in the Western part of the world so that they can detect the AF patient, whether it is non-valvular, because in Western Part definitely non-valvular is more prevalent (03:00) than the valvular part, so they have so many registries regarding the screening part of the atrial fibrillation. So what is your opinion on that. These kind of screening registries and the screening program, should we have in Indian prospective also so that at earliest level we can detect the AF cases at appropriate time?
Dr. Guru Prasad: Certainly, because I just say one group, I am a visitor professor to Kathmandu University. I take the country of Nepal. It is a small country where we can have the true data and probably we can extra pull it the same data because it is almost neighbouring country to India. In our study, probably first study in that part of the world, may be it is equally true that in Indian statistics as well, so what we found in our study was (04:00) this atrial fibrillation in relation to structural heart disease and then nonstructural heart disease. So overall atrial fibrillation it is 35-38% related to rheumatic valvular disease and 30% is related to degenerative valvular disease in elderly patients like calcific aortic stenosis and calcific mitral valve disease and some 20% related to cardiomyopathy. Lone atrial fibrillation are non-valvular atrial fibrillation where heart is structurally normal, probably it comes around 10-20%, so probably I can say this can be the same in India as well. So some 10-20% you know like lone atrial fibrillation are non-valvular atrial fibrillation. (05:00) but at least we can see in India as you know places equivalent to developed countries and under developed, I mean the poor, we have the two extreme cohorts. So still the rural area, rheumatic and other valvular diseases they prevail atrial fibrillation and in cities metros especially, developed states and developed cities, they are on par with like you know developed countries where the non-valvular atrial fibrillation is at least increasing rapidly. So in relevant to how best we can detect and diagnose. The thing is you know we have at least most of the educated people in India, they have the tendency of having annual check ups, health check ups and of course in rural areas, it is both, you know professional from the doctors as well as the policy makers that you know we need to identify the patients and then make (06:00) a data base and then register, but sometimes patients, most of the rural population, they come with the symptoms not just because they have atrial fibrillation, because of the heart disease, so may be chest pain, breathlessness, may be syncope or with established complications like stroke or any embolic phenomenon. So then atrial fibrillation is accidentally diagnosed retrospectively. Yes, in an asymptomatic patient at least you know from our professional side the may be tertiary care hospital at least what we suggest and actually we are doing is making a registry data base and patients with non-valvular atrial fibrillation are only atrial fibrillation without structural heart disease, (07:00) so definitely we are lacking true registries, true data incidence and prevalence and how best we can detect. It is very simple, it is a most common arrhythmia and all arrhythmias are best detected by simple physical examination by checking the pulse as well as taking an ECG. Well, if patients say that I have palpitation once in a while and on baseline normal clinical exam, pulse is regular, ECG is normal, it could be any arrhythmia. So the best way to detect is like 24-hour Holter monitor or event monitors like external loop recorder, internal loop recorder. So in an asymptomatic individual where we suspect atrial fibrillation is the cause of arrhythmia, there baseline parameters are normal, may be the best way is Holter or event monitors like external loop recorder or internal loop recorders. That is the best way to detect and document and evaluate for the further proceedings of how to treat the patient.(08:00)
Dr.Kunal Jhaveri: It is definitely, it is very well said and even though guidelines are also now suggesting that as the term is opportunistic screening when a patient having age of something like more than 65 years then at least, what you say that at least the basic palpation method and ECG should be the part of your diagnosis, then apart from other cardiovascular disease, if patients have atrial fibrillation without any symptoms then definitely it can be detected at that time and treatment can be started as soon as possible.
Dr. Guru Prasad: Still ECG is an indispensable tool.
Dr.Kunal Jhaveri: No doubt about that surely. So definitely. Now sir if we go about the management part, as we know that in AF rate, rhythm control and apart from that the prevention of complication is also very important. Like a stroke prevention, atrial fibrillation. So since almost 1950s the VKA and the older oral anticoagulants what we can say they are available and still there are the goal standard treatment but now since almost (09:00) four to five years, we have seen the newer generation of oral anticoagulants available. So sir in your practice, how do you have differentiate both the molecules and what is the challenge you have found with the VKA so that you made your decision to shift in some patients to oral anticoagulants to the newer oral anticoagulants.
Dr. Guru Prasad: Because especially after 60 years you know the European database or registry say that after 60 years the prevalence rates of A Fib is high and especially may be even in India after 40 years I can say based on life expectancy and we all know that you know any patient with atrial fibrillation has four to five fold increased risk of stroke. So definitely in a patient of ischemic or hemorrhagic stroke sometimes in relation to atrial fibrillation is definitely under (10:00) reported, especially in the remote areas in India. So treatment is also challenging especially where we have all sorts of patient groups, structural versus nonstructural heart disease. So the legendary star molecule nearing 60 years or so, we know well about Coumadin, warfarin, acenocoumarol and all, so I must say that has been only drug till a few years back, where we have to prescribe and then test the patient for PT and INR and compliance, of course everybody and any doctor who prescribes these vitamin K antagonists knows that. It is a double edged sword. It is a good drug as well as it is a bad drug, bad drug in the sense that compliance and the side effects. So we (11:00) all know that the patient needs to be monitored at least once in a month because the therapeutic window is very narrow. It should not be you know the INR like 2-3 exactly and less than that is ineffective and more than that has high bleeding risk. Even if you stop the drug because its half life is long up to 40 hours, so the effect takes long even if you stop the drug to control the bleeding. Testing these PT test INR with good quality in remote areas is truly difficult and compliance of the patient not more than 20-30%, especially in rural areas, so certainly we do face lot of problems by prescribing this warfarin or Acitrom (12:00) but still there is no go for a village patient who wants to get the tablet in a PHC and that has to be prescribed and we warn them of course. Like you know they are the potential, so it has lot of drug interactions, lot of food interaction, lot of compliance issues and then of course bleeding complications. So definitely it is a good drug and the advantage is it is effective and it is well known molecule, more than half century, but of course we do need, if there is any drug with us which can bypass all these adverse effects like you know, short duration of action, for example 24 hours, it should work for 24 hours with single dose and no need of testing or monitoring and it should be affordable, so all three Es, should be (13:00) effective, efficacious and then economical and it should be easily available. Every practitioner who treats atrial fibrillation certainly dreams about a molecule like this. It is good that we have Noax in this decade that we started treating atrial fibrillation with this Noax, though of course they are newer molecules but they are well proven in clinical trials that they are really effective and certainly non inferior, to some extent some drugs they are superior to warfarin with less complications, we do welcome that, the long-term stay and safety may be we need to wait for the time.
Dr.Kunal Jhaveri: So definitely sir, during your discussion what you have mentioned, one point is very correct regarding the compliance issue. As you know, when the patient has atrial fibrillation (14:00) the treatment will remain for a lifetime for prevention of a stroke. Because at any point of the age without treatment, patient has a very high chance for developing the stroke and as you also mentioned that VKA, warfarin, Acitrom these drugs are available since last almost 50 to 60 years but still the practical challenges like PT monitoring, INR monitoring which is not willingly done by the patients and that is why the compliance remains low around 25-30% at the end of the first and second year. So sir what do you find, also you mentioned that if the drug is available as a once daily dosage without INR monitoring required and it is proven efficacy and proven safety, so sir in Noax part, we have as of now three drugs in India, rivaroxaban, dabigatran and Apixaban. In that if you say that once daily like the rivaroxaban is once daily. Dabigatran and apixaban is also advantageous in some other part regarding the ischemic stroke and regarding the GI bleed, so all three Noax are available so how will you position this all three Noax in your clinical practice, if you want to prescribe a Noax then (15:00) how will you position these three drugs?
Dr. Guru Prasad: Certainly you know, Noax they have proven, they have established at least in treating the non-valvular atrial fibrillation at least they have proven, they have established their role and stand in treating this. I must say, because you know all of them they are compared to warfarin. It is not head-to-head comparison and warfarin comparison, they compared, so all the three drugs that is dabigatran which is direct thrombin inhibitor and the factor 10 inhibitors apixaban and rivaroxaban, (16:00) so for me personally because I have a little experience of using all the three drugs for the past few years, I must say all are good, may be say out of 100, the three guys got some 95 marks, 94.5 or some 94.0 just one percent plus/minus this way, but I must say you know after treating the patients and with the available evidence and after extensively analyzing the publications, the research data, I must say you know they all are good of course and still I want to be choosy. To some extent though we follow the guidelines, what is my aim in treating this patient. Based on that I choose the molecule. So what is his CHADS-VASc score or HAS-BLED score, whether he belongs to the stroke risk, whether low intermediate or high risk of stroke and other comorbidities (17:00) like whether patient recently underwent stenting or MI or heart failure. So I consider overall not just atrial fibrillation because atrial fibrillation is the only the tip of the iceberg, it is rather a syndrome, that is why we not only see the atrial fibrillation, we see a lot of heart failure, diabetes, renal and everything in treating atrial fibrillation. For me in summary, all the Noax that are available are all good and they have been proven in efficacy, safety wise as well with no need of monitoring. The best part is they do not need monitoring as of now and of course even antidotes have come up in case of over dosage, so I can put of course within the range of 0.5 to 1% +/- all are equally good.
Dr.Kunal Jhaveri: So as you mentioned that there is no as of now head-to-head trials available, so it is very difficult to judge anybody that who is superior and who is (18:00) equal and who is inferior definitely, but as you mentioned very well that even though if you have taken the feedback from other practitioners as well, all three as of now are good, some have some minus points, some have plus points, if we see the overall, all three drugs are almost safety and efficacy wise they are very good. So, sir this is just the last question for you that as you are an interventional cardiologist, so you must have many patients for the acute coronary artery syndrome. So that patients post stenting or any kind of bypass grafting they might be developing atrial fibrillation because in this kind of condition the chance of A Fib development is very high. So now this is the catch point. As of now there is no any established data that patients having AS and AF then how the Noax can be used or even warfarin can be used along with DAPT. Because the DAPT is a must when you are doing the stenting to prevent the stent thrombosis and recurrence of MI. Now for the part of atrial fibrillation if you want to add any kind of (19:00) oral anticoagulants, say Noax like rivaroxaban which is proven for the ACS also as well. So how, even acenocoumarol also suggested something like that you should continue with the DAPT then you can follow with the oral anticoagulant for a lifetime, so what is your consideration because still it is one of the grey area what we found that how we can discuss with the other doctors also.
Dr. Guru Prasad: This is very important question and the situations where we face day-to-day in treating patients you know we not only treat atrial fibrillation it is not just atrial fibrillation what we need to treat, it is a complex patient in a complex situation in a clinical scenario, real world scenario. So that is where we need to face lot of challenges because the trials screen only nice patients for the inclusion criteria and exclude at least initially for the safety data, but in real world (20:00) we need to face lot of problems in treating patients. Well I can summary like this, what your patient needs exactly is just non-valvular atrial fibrillation with a high chance of stroke, like high cumulative score of CHADS-VASc versus low to intermediate or intermediate to high young patient with multiple risk factors like what you said, acute coronary syndrome. So it is not just my own thing. Based on the evidence I can say that, see in the rely data the dabigatran has shown a little bit, so they say statistically not significant and even FDA has an alert on that and there were some more investigations went on so to analyze the state of little bit of high incidence of MI after using dabigatran, but they say statistically, so they say now 1 in somewhere between 470 patients (21:00) one coronary event. But there is of course a trend of increasing MI or ACS in patients on dabigatran and apixaban may be I can say it is neutral or may be effective but this has clearly shown that 16% reduction in cardiovascular, especially MI related events and it is even proven in the mortality benefit. Mortality benefit specifically I mean in relation to MI related event, so 16% reduction. So may be in relation to your question like if a patient of ACS who needs (22:00) Noax, so definitely I can prefer rivaroxaban in that because we have the data evidence to say that the rivaroxaban is effective in ACS rather. It lowers the incidence of ACS, those who are already on it and if already patients on dual antiplatelet developing atrial fibrillation. Based on current guidelines they say first thing is we need to risk stratify, whether it is moderate to high risk of having stroke, then we have to use with dual antiplatelet with Noax, preferably rivaroxaban at least four to six weeks. If it is high risk of stroke, not only stroke, high risk of bleeding as well, here what is important is HAS-BLED score. If HAS-BLED score is very high, the patient may bleed (23:00) at least you know more than 3-4 HAS-BLED score, so then four to six weeks of dual antiplatelet with Noax then later on continue with one antiplatelet with Noax for an year and then decide later. Provided patient is having low to intermediate risk of HAS-BLED, so bleeding chance may be up to six months we can use dual antiplatelet with Noax preferably rivaroxaban and later we can decide like with Noax with one platelet up to an year and then decide risk stratify. So this is based on the current guidelines and then evidence. So simply if HAS-BLED score is high, use it for four weeks and then decide with one antiplatelet and rivaroxaban. If it is low risk you can continue dual antiplatelet with rivaroxaban up to six months and then after six months one antiplatelet and rivaroxaban up to one year and then decide later (24:00). So we need to know the CHADS-VASc score, HAS-BLED score and the risk profile of the patient and definitely the bottom line is in the sitting of acute coronary syndrome as an interventional cardiologist, I definitely prefer rivaroxaban.
Dr.Kunal Jhaveri: Yeah obviously, because So definitely sir, lastly what we have discussed regarding the atrial fibrillation its screening issues and VKA and Noax is beneficial but they have also some own concern regarding the ACS and atrial fibrillation part. So if from your side if I want to summarize this discussion in just five bullet points then how you will you put it from your side?
Dr. Guru Prasad: So there is no doubt that atrial fibrillation needs these massive bullets and definitely they are going to be prescribed in more lot and lot in future. I can summarize (25:00) all the three Noax. If your aim is to reduce the stroke risk alone including intracranial bleed may be we have dabigatran. If we do not want bleeding risk, so patient has high chance of bleeding, so you want just to play safe, in between, may be Apixaban. If you have really patient compliance issues like, I cannot take more pills, only one pill and I do not want monitoring and any risk category because has shown it is the only trial that has shown up to 3.5 CHAD score. So at least moderate to high stroke risk CHADS-VASc score, and patients especially for a cardiologist where we do lot of interventions, where cardiac patient is there apart of atrial fibrillation and patient does not want more pills, it is definitely safe. So I prefer rivaroxaban certainly. So that would be my summary.
Dr.Kunal Jhaveri: So sir definitely we are very grateful for all your thoughts and your own opinions and your discussion part, it is very helpful for us and we can take this suggestion to increase the awareness regarding atrial fibrillation, its management and the screening part as well to further medical fraternity as well. So Dr. Guru Prasad, it is very very thankful to you and it is my pleasure that you have come
Consultant paediatric Cardiologist and Electro Physiologist
SCB Medical College
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