Atrial Fibrillation Of The Heart: The Value Of Options
Patient Perspective Atrial fibrillation (AF) is a heart condition affecting roughly three percent of all North Americans.
AF is characterized by irregular or rapid beating of the heart, and it can lead to serious complications such as stroke. For peoplesuffering from AF, it can be both confusing and frightening.
When Alice first experienced symptoms of AF, she was sitting on her couch watching TV and suddenly felt her heart racing as though she were running a marathon. She was promptly diagnosed at the ER, but in many ways that was the beginning, not the end, of her troubles. Suggestions from doctors on how to manage her AF seemed to vary with each new doctor she talked to.
At the heart of the matter are the many faces of AF. The potential causes of AF are wide-ranging, and the ideal treatment for each individual can be equally varied. Uncertainty about treatment leads to fear. “For the first while I didn’t want my husband to leave the house,” says Alice. “That’s how afraid I was of it.”
Convenience and compliance: just as vital as efficacy
Historically, the AF drug of choice has been Warfarin, an anticoagulant. It’s a very effective drug, in use since the 50s, but it has its downsides. There are people who are resistant to it, or who have drug-drug interactions, but most importantly it requires constant monitoring of blood thinning levels, which means frequent trips to labs for testing.
For many Canadians, this is a substantial hardship in terms of time off work as well as travel time and expenses, especially for more remote patients who must travel long distances for lab work.
“Because Warfarin is such a pain in the neck, we had a pretty high bar a patient had to clear before we would begin on anti-coagulants,” says Dr. Jafna Cox, who has been heavily involved in the development of national guidelines for the treatment of atrial fibrillation.
A new class of drugs, known as novel oral anticoagulants (NOACs), however is changing the landscape. “At the end of the day, they are not that much more effective than Warfarin, but what they do offer is marked ease of use. They’re easier to take and thus hopefully have better patient compliance.”
And with AF, drug compliance is of paramount importance. A recent study of AF patients in Ontario found that 61 percent stopped taking the drugs within five years, drastically increasing their risk of stroke. Furthermore, AF strokes tend to be both larger and more consequential than non-AF strokes, with a substantially higher rate of both mortality and permanent incapacitation.
Real world data trumps all
So, if NOACs can improve compliance, and convenience, without sacrificing efficacy, they have the potential to be a game changer. As with any new treatment, of course, the true test comes from real-life data. “Often in clinical trials, out of 100 patients that you screen, you may only have five accepted into the study because you have exclusion criteria after exclusion criteria,” says Dr. Cox. “So you always wonder, do you have patients that are too uncomplicated, with too few other conditions?”
As these new drugs make their way into clinical use, the good news is that the real-life data is beginning to reaffirm the safety and efficacy of the NOACs that was seen in the clinical trials, with a safety profile substantially better than Warfarin’s. While NOACs will not be the answer for every patient, they benefit everyone by expanding the toolkit available to physicians. This is great news for patients like Alice who now have new options for managing their life with atrial fibrillation.