Singapore - Cardiovascular diseases including heart diseases and stroke account for one-third of deaths (nearly 18 million) throughout the world, according to a new scientific study that examined over 130 countries in the past 25 years. Stroke was the second-leading cause of global health loss, with nearly 9 million first-time strokes globally. Mirroring the global burden, heart diseases and stroke are significant causes of death and disability in Asia. In Singapore, stroke is the 4^th leading cause of death and the largest cause of long-term physical disability. The latest figures from the National Registry of Disease Office show that there were 6,943 cases of strokes in 2014, up from 6,642 in the previous year. With a rapidly aging population, the burden of stroke is expected to increase exponentially, posing challenges to the healthcare system and society.

Recently, Bayer hosted renowned cardiologist Professor Robert Welsh from Mazankowski Alberta Heart Institute and University of Alberta in Edmonton, Canada and Adj Assoc Prof Ching Chi Keong, Senior Consultant with the Department of Cardiology at the National Heart Centre Singapore who gave an insight on the latest highlights in the management of stroke due to AF, latest international guidelines, trends and clinical experience with the use of NOACs in AF stroke prevention. They also talked about the burden of AF associated stroke and current gaps and challenges in managing the condition in Singapore.

The impact of AF associated stroke

Atrial Fibrillation (AF), a heart condition characterized by irregular heartbeats, increases the risk of stroke caused by blood clots by five-fold^. Strokes due to AF are more severe, causing disability in over 50% of patients and generally worse outcomes than strokes due to other causes. In Singapore, AF is the most common heart rhythm disorder. The prevalence of AF increases with age. Hence, it is a growing concern in Asia and in Singapore due their rapidly aging populations. It is estimated that in 2050, Asia will have 72 million AF patients, and 2.9 million among them will suffer from an AF-associated stroke.

Unmet Needs in AF Associated Stroke Prevention

The good news is AF-related stroke can be prevented. However, there is still a significant number of AF patients in Asia and Singapore not receiving optimal anticoagulant therapy for stroke prevention.

Older anticoagulant therapy with Vitamin K Antagonist (VKAs) such as warfarin makes effective anticoagulation harder for patients and physicians due to its manifold food and drug interactions, regular blood monitoring requirements and risk of intracranial (skull) bleeding. These serious disadvantages cause VKAs to be under-used or under-dosed AF stroke prevention, leaving patients unprotected.

The introduction of non-vitamin K antagonist oral anticoagulants (NOACs) brings new hope to patients. NOACs like Xarelto (Rivaroxaban) match warfarin in stroke prevention, but are easier to administer and significantly reduce the risk of life-threatening bleeding, particularly intracranial (skull) bleeding. The latest international guidelines recommend NOACs as first-line therapy for the management of AF-associated stroke, stating that NOACs offer better efficacy, safety and convenience compared with VKAs. NOACs are broadly preferable to VKAs in the vast majority of patients with AF.

Latest Trends in Anticoagulant Therapy Usage

Globally, with introduction of NOACs, patients receiving anticoagulant treatment for stroke prevention have increased substantially according to GARFIELD-AF, the largest ongoing prospective registry of patients with AF worldwide. The study enrolled 57,262 patients from over 1,000 centres in 35 countries worldwide, including from the Americas, Europe, Africa and Asia-Pacific.

The change in treatment patterns over the past five years suggests a greater clinical emphasis on stroke prevention.

The study also showed that Asia and Singapore are behind the world in anticoagulation in AF stroke prevention, with still a high rate of non-therapy and VKA usage. In Asia, almost 20% of patients with AF receive no therapy and more than 60% of patients still receive either VKA (with or without antiplatelet therapy) or antiplatelet therapy only. In Singapore, it is a similar situation. The importance of anticoagulation and benefit of using a NOAC over VKA is still not fully understood by the general public.

Closing the Gaps in AF Stroke Prevention in Singapore

In Singapore, Xarelto has recently been included in the Medication Assistance Fund (MAF) to be eligible for government subsidies based on its proven clinical and cost-effectiveness recognized by Singapore Ministry of Health. The recent guidance from the Ministry of Health advances the decision-making process that supports doctors and patients to select the appropriate drug based on the patient's medical condition. This move will allow more people in Singapore access to first-line anticoagulants like Xarelto, which has proven real world evidence that confirms highly effective stroke prevention in patients with AF and low rate of major bleeding. Xarelto is the most studied NOAC in the world today, with a robust clinical program, which by the time of its completion, is expected to include more than 275,000 patients in both clinical trials and real-world settings.