Treating NVAF-Related Strokes: Future Outlook

Gary M. Besinque, PharmD, FCSHP; Jaime E. Murillo, MD; Juvairiya Pulicharam, MD; Ralph J. Riello III, PharmD, BCPS; and Peter Salgo, MD, provide their expectations for the future treatment of nonvalvular atrial fibrillation-related stroke.

Peter Salgo, MD: What does the future for treating nonvalvular atrial fibrillation-related stroke look like? I guess there are 2 parts to my question. One is prevention, and the other is, what do we do about it once you get it? What does the future look like here?

Ralph J. Riello III, PharmD, BCPS: I think the future is probably in using sophisticated and integrated electronic health records to tease out the patients who are within a given healthcare system that are at risk for stroke—CHA₂DS₂-VASc scores of 2 or more who aren’t prescribed anticoagulation. We need to find a way to screen and pull them into the clinic, to get them on appropriate therapy.

Peter Salgo, MD: OK. What about you? What do you think?

Juvairiya Pulicharam, MD: I think it’s important, like he said—identifying who is at risk and bringing that education to patients, physicians, and the health system. And, creating a care pathway that we can follow.

Peter Salgo, MD: Controlling atrial fibrillation [AFIB] sounds like a good idea. If we could stop that, we wouldn’t be having this conversation. Where are we with that?

Jaime E. Murillo, MD: I love that question, and I’ll tell you why. We see this increasing prevalence of atrial fibrillation. When I was at Yale, I remember an instance when someone said, “Atrial fibrillation will be the epidemic of the 21st century.” He was so right. We all say it’s because we’re getting older—because we live longer. I still believe, and this is, again…

Peter Salgo, MD: Unpublished statements.

Jaime E. Murillo, MD: Yes. There has got to be something that is causing us to have so much atrial fibrillation. Not just the elderly population has atrial fibrillation. I see quite a few young patients with atrial fibrillation. Is there something about our environment? Are we eating the right stuff? Is there a change in lifestyle that we are ...

Peter Salgo, MD: Coffee? There is no life without coffee. Can we take that off the table?

Jaime E. Murillo, MD: No. You’re talking to a Columbian. Coffee is good for you.

Juvairiya Pulicharam, MD: Is it the stress?

Jaime E. Murillo, MD: Is it? I think that’s also where we have an opportunity—to try to figure out what is causing this increase in prevalence. We can’t just say it is caused by hypertension, diabetes, or vascular disease.

Peter Salgo, MD: You said anxiety, and I’m not sure that’s related to AFIB either.

Juvairiya Pulicharam, MD: No, I’m just saying that there must be something. I agree with that. We have seen a lot of disease states. Most of the time, I give this answer: “Because we’re living longer.” That could be it, but our lifestyle, and the way we eat—all of these things have changed big time. And, we don’t get as much rest.

Peter Salgo, MD: For some of us.

Juvairiya Pulicharam, MD: For many of us. I think lifestyle, no rest, and the fact that we’re always working… So, the anxiety is there. And, we do need more coffee. And, different medications. Could it be the statins? Could it be caused by all of these drugs that we’re all taking? Could it be the aspirin?

Peter Salgo, MD: For the record, I know of no study that shows that the incidence of AFIB increases with coffee used chronically. Do you know of one?

Jaime E. Murillo, MD: No. There are actually studies that have shown no significant effects of coffee on heart disease.

Peter Salgo, MD: This has been a tremendous discussion, but I don’t want to leave without affording each of you the opportunity to share one last word for our viewers. So, this is your shot. Dr. Besinque?

Gary M. Besinque, PharmD, FCSHP: With all of these really good anticoagulants, we’re going to need to learn how to compare them and use each one of them to its best advantage.

Peter Salgo, MD: OK, short and to the point. Dr. Murillo?

Jaime E. Murillo, MD: We have talked about these 4 words—screening is extremely important. There is an opportunity here, with technology and detection and monitoring. A team approach is key. It’s essential to the true treatment of atrial fibrillation. And the last one is, more research into causes of atrial fibrillation.

Peter Salgo, MD: Dr. Pulicharam?

Juvairiya Pulicharam, MD: I think it’s important to understand the root cause so that we can understand how we’re going to take care of these patients. And then, education is still a gap. So, I would like to focus on that. And then, maybe more real-world data—maybe registries to help look at treatment patterns. And finally, we need to really focus on decreasing that gap in education, working very collaboratively with different team players who provide care.

Peter Salgo, MD: And Dr. Riello, you’ve got the last word.

Ralph J. Riello III, PharmD, BCPS: My closing thoughts are probably going to be 2-fold. From a population health perspective, you mentioned that AFIB is the next epidemic of the 21st century. We should treat it like a public health initiative. That’s done through better identification and screening, and through using our electronic medical record tools—integrating them to really tease out those patients in the health care system. Then, once you have found them, engaging them in shared decision making and early education, upstream, to make sure that they’re on the right drug, can afford it, and are comfortable taking it.

Peter Salgo, MD: What a great discussion. I want to thank all of you for being here. I want to thank you for joining us and for watching our panel. I hope that you found thisPeer Exchangediscussion to be useful and informative. I’m Dr. Peter Salgo, and I’ll see you next time.

Juvairiya Pulicharam, MD: Thank you.