The heart that flutters
A new treatment for atrial fibrillation is introduced at a recent medical conference but will it be too expensive for Thai patients?
Most of us associate a rapidly pounding heart, shortness of breath and even chest pain with a lack of sleep, stress or a heart attack. While they are not uncommon symptoms in any of these conditions, they might also be signs of atrial fibrillation, the medical term for an abnormal heart rhythm.
“However, most of the time we only discover AF when we are seeing the patient for something else entirely. The patient doesn’t know that his or her heartbeat is abnormal. It’s not easy to detect as it’s not constant and might not happen while they are consulting a doctor,” says Dr Pinij Keawsuwanna, who heads the Cardiovascular Disease Centre at Maharaj Nakhon Ratchasima Hospital.
AF, which is also called arrhthymia, and A-Fib, occurs when the upper chambers of the heart beat irregularly rather than effectively to move blood into the ventricles. An irregular heartbeat leads to the risk of clotting, which can travel to the whole body. AF becomes dangerous if the clot travel to the brain and blocks circulation in that area, resulting in a stroke. Clots can also damage other organs and may lead to heart failure.
The treatment a patient receives once diagnosed with AF varies according to their symptoms. Generally it involves interventions that restore the heart to a normal rhythm and controls the heartbeat and through medications that prevent complications from blood clots and thromboembolism.
Restoring the heart to a normal rhythm is done through a procedure known as cardioversion. This can take three forms: Pharmacologic cardioversion – ie medication – electrical shock and radio frequency ablation to restore the damaged area though in this case, the AF sometime returns.
In Thailand, most AF patients receive oral anticoagulant therapy with vitamin K antagonist drugs, the most common of which is warfarin.
Warfarin has been used for decades in preventing clotting but comes with complications as the medication interacts with other drugs such as antibiotics, statins and NSAIDS. It also interacts with foods with a high concentration of vitamin K such as broccoli and green leaf vegetable.
That means any patient requires careful monitoring, monthly blood tests and dose adjustment.
Another side effect is the bleeding. This can occur when there’s an imbalance in the dose and can lead to death.
Rivaroxaban was introduced some time ago as an alternative to warfarin and offers certain advantages for patients. First, it does away with the need for monthly blood checks and is taken just once a day, generating better compliance and making it a safe alternative to VKA therapy. On the negative side, it’s out of reach for many Thai patients as it costs more than Bt100 a tablet as opposed to warfarin’s price of just a few baht,
“In general practice, we still use warfarin for AF patients but the new drug is alternative way for patients who can afford it as well as for those who can’t take warfarin because of its side effects,” Dr Pinij says.
A newer version of Rivaroxaban was recently introduced at the European Society of Cardiology Congress in Barcelona, Spain after a series of studies on patients. Taken once daily, it has proved effective in patients undergoing either electrical or pharmacological cardioversion and has been shown to be a consistent and more predictable anticoagulant than warfarin.
In Thailand, where the most common cardivoersion is radiofrequency ablation, which uses frequency to destroy the problematic areas and can cost up to Bt150,000 a time in public hospitals, the expense of this new drug may well prove a life-saver for those suffering from AF.
