role newer anticoagulants in prevention of stroke in AF

1. Patient of AF stable on warfarin, should
we switch over to NOAC
Dr Siva Subramaniyan
PGIMER &Dr.RML Hospital
New Delhi

2. Introduction
• Atrial fibrillation (AF) is the commonest sustained cardiac arrhythmia, and
represents a global problem
• The absolute numbers of patients with AF in Asia are substantially higher than
Europe or the United States
• AF confers a substantial risk of mortality and morbidity from stroke,
thromboembolism, heart failure, cognitive impairment and poor quality of life,
the public health and healthcare burden associated with AF is huge

3. • Stroke prevention is central to the management of AF, given the increased risk of
stroke and thromboembolism associated with this arrhythmia.
• It is well established that effective stroke prevention requires OAC, the problem
until recently was compounded by the substantial numbers of patients in Asia
that are not treated with OACs (usually VKAs, e.g. warfarin), and even those
managed with VKAs have poor quality anticoagulation control.
• Today’s clinician is faced with the difficult task of selecting a suitable OAC for a
patient with a particular clinical profile or a particular pattern of risk factors and
concomitant diseases

4. Anticoagulants
We have
• Vit K antagonist
• NOACs

5. Limitation of vit K antagonist

6. Bleeding events on warfarin in Asians vs non-Asians
B. Intra-cranial haemorrhage
Gastrointestinal bleeding D. All (major plus minor) bleeding
episodes.
A. Major bleeding

7. Maintaining INR in Asians is a problem

8. Warfarin discontinuation rate is high
A total of 1461 patients with NVAF who were newly started on warfarin

9. NOACs
FDA approved NOACs are
• Dabigatran
• Rivaroxaban,
• Apixaban and
• Edoxaban.

10. Evolution of NOACs

14. Integrated management of patients with atrial fibrillation

15. ASSESSMENT OF RISK

16. BLEEDING RISK

17. efficacy endpoints with NOACs vs warfarin in Asians vs non-
Asians
Stroke and systemic embolization events

18. Haemorrhagic stroke in Asians from 4 RCTs
Haemorrhagic stroke

19. Myocardial infarction in Asians from 4 RCTs
Myocardial infarction

20. All-cause death in Asians from 4 RCTs
All-cause death.

21. Adherence with NOACs is good

22. NOACs in CAD

23. Which NOAC in CAD ?

25. NOACs in CKD

26. MANAGEMENT OF NON-VALVULAR AF IN ASIANS

27. Which NOAC ?
Factor to consider
• Age of the patient ?
• Renal impairment ?
• Bleeding risk ?
• Prior stroke ?
• Risk of MI ?
• Potential drug interaction
• Patient reference OD ?
* Compared to warfarin in trials.

30. Disadvantages of NOACs

32. Conclusion
• Incidence of stroke/ TIA in patients with AF higher in Asians
• The risk of ICH is twofold that of whites and fourfold when warfarin used
• In 4 trials comparing NOACs with warfarin in Asian patients significant reduction
in stroke/SEE with dabigatran 150mg with nonsignificant trends to lower rats with
other NOACs
• Evidence suggest that NOACs is better than warfarin in terms of efficacy and
safety outcomes

33. • ICH consistently lowered by all NOACs
• NOACs is preferred in Asians over warfarin due to poor INR control and increased
IC bleed
• Persistence and adherence of NOACs is better than warfarin
• ESC AF 2016 guidelines favour NOACs over warfarin as a initial therapy