You can earn 1 General CPD point by watching this webinar recording of the first in Zydus’Master Stroke webinar series.

The event was held on 3 April 2024 and featured short presentations on stroke by:

• Dr Anil Saxena (India)
• Dr Anomali Vidanagamage (Sri Lanka)
• Dr Mahmoud Al-Naili (South Africa)
• Dr Michael Joseph Agbayani (Philippines)

Click here to watch the event

The goal of the talk was to shed light on the latest advancements in cardio-cerebrovascular medicine. The first speaker, Dr Anil Saxena, spoke about the relationship between atrial fibrillation and stroke prevention, and the process of choosing a NOAC for stroke treatment. "Atrial fibrillation is extremely common and we are experiencing a global epidemic of it at the moment," Dr Saxena said. "As the population is aging in the developing countries, we are looking at a further rise in incidence and prevalence of atrial fibrillation."

According to Dr Saxena, there was a time, 20 to 30 years ago) when the risks of atrial fibrillation were not understood, but we now know that atrial fibrillation confers about four to five times risk of stroke compared to normal sinus rhythm. Dr Saxena emphasised that atrial fibrillation risk needs to be individualised. "One important thing to understand is the importance of surveillance because, unless we recognise atrial fibrillation, we cannot understand the risk or even do anything to modify that risk."

Most patients need to be given anticoagulation at some point after atrial fibrillation commences, Dr Saxena said, to the point where much of the surveillance effort comprises identifying patients who do not need to be given anticoagulation. Luckily, the safety profiles of ost NOACs are excellent.

"As far as NOACs are concerned, it's very important to understand that dabigatran is largely cleared by the kidneys, about 80% clearance by the kidneys, as compared to rivaroxaban, which is about 35% cleared by the kidneys. Apixaban seems to have the most diverse elimination profile with only 27% eliminated by the kidneys and 73% by the liver and some directly excreted in the gut. And edoxaban is 50% eliminated by the renal root. So it, it is very important that we reduce the dose of that in patients who have renal dysfunction."

WHICH NOAC TO USE?

According to Dr Saxena, patients with recurrent stroke or patients who have a stroke while on anticoagulants, should consider switching to the regimen which has shown the maximum efficacy, namely 150mg dabigatran twice a day, provided the patient has no contraindications. "If the patient has moderate to severe renal impairment, then of course apixaban is the logical choice because it has minimal renal clearance. If the patient is at high risk of GI bleeding, then again apixaban is probably the best choice. Otherwise we can use 110mg dabigatran, although that can cause some dyspepsia.

Dr Saxena believes patients who have highest risk of bleeding can either use 110mg dabigatran or apixaban. And in patients who prefer once daily doses, rivaroxaban is a choice agent.

How is thrombolysis managed in Sri Lanka? Are there limitations on the NOAC dosages one can use after 75? Are they underdosing patients in the Phillipines? Click on the link above to watch the full webinar and qualify for 1 General CPD point. 

NOTE: If you are not registered with HPCSA or you did not complete a registration process in order to access this webinar, please send an email to John.Woodford@newmedia.co.za with your name, surname and MP or P number after viewing it. The same applies if you’re registered in a foreign country like Namibia, Botswana, etc.