For the first time in the country, 14 leading cardiologists from across the country have launched 'Indian consensus guidance on stroke prevention in atrial fibrillation' to help doctors with diagnosis and management procedures to prevent stroke in patients with atrial fibrillation (AF).
The last ten years have seen rapid strides in the evolution of nonvitamin K oral anticoagulants (NOACs) for stroke prevention in patients with AF. This Indian consensus document provides guidance on selecting the right NOAC for the right patients by formulating expert opinions based on the available trials and Asian/Indian AF subpopulation analyses of these trials.
The consensus guidance was formulated by 14 leading Indian cardiologists, hematologists and SPAF Academy India experts (part of SPAF Academy Global) which is a 35-member steering committee of key cardiologists, neurologists, haematologists across India to address challenges faced by doctors in stroke prevention in the country.
Dr. Jamshed Dalal, director, Centre for Cardiac Sciences, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Abhay Bhave, honorary consultant haematologist, Lilavati Hospital and Research Centre, Mumbai, Abraham Oomma, senior consultant cardiologist, Apollo Hospital, Chennai, Amit Vora, electrophysiologist, Arrhythmia Associates and Glenmark Cardiac Centre, Mumbai, Anil Saxena, director, Cardiac Pacing and Electrophysiology, Fortis Escorts Heart Institute, New Delhi, Dhiman Kahali, senior consultant Interventional Cardiologist, BM Birla Heart Research Centre, Kolkata, were among 14 cardiologists who formulated the consensus guidance.
The consensus is published in the December 2015 edition of ‘Indian Heart Journal’.
Stroke or a brain attack is the second largest cause of death in India. If not managed appropriately, 1 in 20 AF patients may develop stroke every year.
AF, an irregular heart rhythm (arrhythmia) of up to 300 beats/min (4 times than normal), is a high risk factor for stroke. Most common risk factors for AF include old age (>60 years), high blood pressure, heart failure, heart disorders, prior history of open heart surgery, thyroid disorder, diabetes, chronic lung disease, excessive alcohol intake etc. AF can cause a blood clot in the heart which may travel to a person’s brain, preventing normal blood flow and hence resulting in stroke.
Immediate and proper management of stroke is required to prevent death or paralysis. However, there are challenges in management of stroke prevention in patients with AF the most frequent being low diagnosis rate of atrial fibrillation, an indication of impending stroke attack; management of acute coronary syndrome (e.g. heart attack); understand the differences in response of Asian and Western patients to blood thinners; matching the right drug to right patients from the new class of available blood thinners.
Highlighting the need for guidelines to address these challenges, Dr. Sundeep Mishra, professor and consultant cardiologist, AIIMS, New Delhi and editor of Indian Heart Journal said, “A stroke incidence due to AF can be prevented if the symptoms are recognized and managed properly. Diagnosing AF and an impending stroke is not just a challenge in India but the world over, as this rhythm disorder of the heart is episodic in nature and remains silent for many years. In fact, for many patients, stroke could be the first presentation. Therefore, there was a need to develop guidelines to advice doctors how to manage stroke in patients with AF.”
Throwing light the preparation and essence of the guidelines, Dr. Jamshed Dalal, director, Center for Cardiac Sciences, Kokilaben Dhirubhai Ambani Hospital, Mumbai said, “The Indian Consensus Guidance will help doctors with diagnosis and management procedures to curb stroke in patients with AF. It also recommends rational use of newer class of oral blood thinners (NOACs) in Indian patients. The guidelines contain evidence on NOACs in Asians including Indians. It provides a risk classification of stroke and bleeding.”
The guidelines were prepared considering following clinical situations: (i) dose recommendations of the NOACs in different clinical scenarios; (ii) NOACs in patients with rheumatic heart disease (RHD); (iii) monitoring anticoagulant effect of the NOACs; (iv) overdose of NOACs; (v) antidotes to NOACs; (vi)
treatment of hypertrophic cardiomyopathy (HCM) with AF using NOACs; (vii) NOACs dose in elderly, (viii) switching between NOACs and vitamin K antagonists (VKA); (ix) cardioversion or ablation in NOAC-treated patients; (x) planned/emergency surgical interventions in patients currently on NOACs; (xi) management of bleeding complications of NOACs; (xii) management of acute coronary syndrome (ACS) in AF with NOACs; (xiii) management of acute ischemic stroke while on NOACs.