Published: 2017-01-05

Unmet need and limitations of current anticoagulation therapy for stroke prevention in atrial fibrillation patients: a questionnaire based study

Maulin Dhiren Mehta


Background: Atrial fibrillation (AF) is one of the commonest of cardiac arrhythmia. Non-valvular atrial fibrillation (NVAF) leads to increase in risks of stroke and death. The ‘stroke prevention in atrial fibrillation’ (SPAF) trial have shown that oral anticoagulation therapy (warfarin) is the most effective drug for SPAF. On the other side, warfarin is associated with the risk of serious bleeding. Complications associated with warfarin lead us to in urge of search for effective, safer and convenient newer oral anticoagulation therapy (NOAC).

Methods: The study was observational, non-interventional and prospective questionnaire based, willingly participated by 20 cardiologists of Vadodara. It was done to assess the prevalence of NVAF, to find out unmet need and limitations of warfarin and future of newer oral anticoagulation drugs.

Results: According to cardiologists, prevalence of NVAF was 2.5-3% in vadodara, India. Prophylactic therapy for SPAF was given after evaluating CHA2DS2-VASc score and choice of therapy was warfarin for 60% of total cardiologists. Total 90% of the cardiologists mentioned that bleeding and continuous monitoring are the commonly encountered problems due to warfarin. According to all cardiologists, warfarin is unsafe due to its serious side effects and change is required. NOAC therapy without antidote can be accepted by all, if they are safe enough. Total 90% of cardiologists mentioned that NOAC drugs must have better safety with comparable efficacy to warfarin.

Conclusions: Safety issues and continuous INR monitoring are the limitations of warfarin. Cheaper NOAC therapy with better safety and comparable efficacy to warfarin is the major requirement.


NVAF, SPAF, Warfarin, NOAC

Full Text:



Furberg CD, Psaty BM, Manolio TA. The prevalence of atrial fibrillation in elderly subjects. Am J Cardiol. 1994;74:236-41.

Jonas O, Jeff HS, Micheal E. Variations in cause and management of atrial fibrillation in a prospective registry of 15 400 emergency department patients in 46 countries. The RE-LY Atrial Fibrillation Registry. Circulation. 2014;129:1568-76.

Bernard JG, Teresa SM, James BS. The changing epidemiology and natural history of non-valvular atrial fibrillation: clinical implications. Transactions of The American clinical and climatological association. 2004;115:149-60.

Fuster V, Ryden LE, Cannom DS. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation-executive summary: a report of the American college of cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines. J Am Coll Cardiol. 2006;48:854-906.

Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I. Guidelines for the management of atrial fibrillation: the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Europace. 2010;12:1360-420.

Tripathi KD. Drugs affecting coagulation, bleeding and thrombosis. Essentials of medical pharmacology. 7th edition; 2013:44:613-633.

Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146:857-67.

Birman-Deych E, Radford MJ, Nilasena DS, Gage BF. Use and effectiveness of warfarin in Medicare beneficiaries with atrial fibrillation. Stroke. 2006;37:1070-4.

Hylek EM, Evans-Molina C, Shea C, Henault LE, Regan S. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation. 2007;115:2689-96.

Connolly SJ, Pogue J, Eikelboom J. Benefit of oral anticoagulant over antiplatelet therapy in atrial fibrillation depends on the quality of international normalized ratio control achieved by centers and countries as measured by time in therapeutic range. Circulation. 2008;118:2029-37.

Melnikova I. The anticoagulants market. Nat Rev. 2009;8(10):353-4.

Connolly SJ, Ezekowitz MD, Yusuf S, Reilly PA, Wallentin L. Newly identified events in the RE-LY trial. N Engl J Med. 2010;363:1875-6.

Eikelboom JW, Wallentin L, Connolly SJ. Risk of bleeding with 2 doses of dabigatran compared with warfarin in older and younger patients with atrial fibrillation: an analysis of the randomized evaluation of long-term anticoagulant therapy (RE-LY) trial. Circulation. 2011;123:2363-72.

Tsang TSM, Gersh BJ. Atrial fibrillation: an old disease, a new epidemic. American Journal of Medicine. 2002;113(5):432-5.

Ogawa S, Aonuma K, Huang D, Huangd JL, Kalmane J, Kamakuraf S, et al. Fact-finding survey of antithrombotic treatment for prevention of cerebral and systemic thromboembolism in patients with non-valvular atrial fibrillation in 9 countries of the Asia-Pacific region. Journal of arrhythmia. 2012;28:41-55.

Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22:983-8.

Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, et al. ARISTOTLE committees and investigators. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365:981-92.

Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on Atrial Fibrillation. Chest. 2010;137:263-72.

Olesen JB, Torp-Pedersen C, Hansen ML, Lip G. The value of the CHA2DS2-VASc score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS2 score 0-1: a nationwide cohort study. Thromb Haemost. 2012;107:1172-9.

Boriani G, Botto GL, Padeletti L, Santini M, Capucci A, Gulizia M, et al. Improving stroke risk stratification using the CHADS2 and CHA2DS2-VASc risk scores in patients with paroxysmal atrial fibrillation by continuous arrhythmia burden monitoring. Stroke. 2011;42:1768-70.

John AC, Gregory YH, Raffaele DC. Focused update of the ESC Guidelines for the management of atrial fibrillation. European Heart Journal. 2012;33:2719-47.

Gopalakrishnan S, Shrinivasan N. Oral anticoagulants: current Indian scenario. Medicine Update 2013;90:410-3. Available at Accessed on 9 October 2015.

Choudhry NK, Saya UY, Shrank WH, Greenberg JO, Melia C, Bilodeau A, et al. Cost-related medication underuse: prevalence among hospitalized managed care patients. J Hosp Med. 2012;7(2):104-9.

Kakkar N, Kaur R, John M. Outpatient oral anticoagulant management: an audit of 82 patients. JAPI. 2005;53:847-52.

Moser M, Bode C. Anticoagulation in atrial fibrillation – a new era has begun. Hamostaseologie. 2012;32:37-9.

Kenneth AB. Pros and cons of new oral anticoagulants; Management of thromboembolic disease. Haematolgoy. 2013;2013:464-70.