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Atrial Fibrillation Stroke Prevention with Oral Anticoagulants
Why is there discordance between guideline committees & specialists when the data is based on the same 3 landmark
trials?
January 2013
April 2015
CCS AF Guidelines
• 2010: • Dabigatran preferred over warfarin
(Conditional Recommendation, High-Quality Evidence).
• 2012: • NOAC preferred over warfarin (note:
apixaban - when approved by Health Canada) (Conditional Recommendation, High-Quality Evidence)
• 2014: • NOAC preferred over warfarin (note:
edoxaban when approved by Health Canada) (Strong Recommendation, High Quality Evidence)
– High value: greater efficacy of dabigatran during a relatively short time of follow-up, lower incidence of intracranial hemorrhage; ease of use
– Less value: long safety experience with warfarin
– High value: greater/similar efficacy, less/same major bleeds, less intracranial bleeds, easier to use
– Less value: long experience with clinical use, antidote, simple/standardized test (i.e. INR)
– High value: greater ease of use, superior/non-inferior, no more/less major bleeding especially less intracranial
– Less value: shorter clinical experience, lack of antidote, lack of simple test for intensity of anticoagulant effect
CCS AF Guidelines GRADE
2014 Guidelines
AHA/ASA 2014 Stroke Prevention Guidelines • Prevention of recurrent stroke in patients with non-
valvular AF:• Warfarin or Apixaban (1A)• Dabigatran (IB) • Rivaroxban (IIaB)
AHA/ACC/HRS 2014 AF Guidelines• Prior stroke/TIA or CHA2DS2-VASc score ≥2:
• Warfarin (1A)• Apixaban, dabigatran, rivaroxaban (1B)
2014 Guidelines
AHA/ASA 2014 Stroke Prevention Guidelines • Prevention of recurrent stroke in patients with non-
valvular AF:• Warfarin or Apixaban (1A) AVVEROES, ARISTOTLE • Dabigatran (IB) RELY• Rivaroxban (IIaB) ROCKET
AHA/ACC/HRS 2014 AF Guidelines• Prior stroke/TIA or CHA2DS2-VASc score ≥2:
• Warfarin (1A)• Apixaban, dabigatran, rivaroxaban (1B)
• ARISTOTLE, RELY, ROCKET
AVVEROES-Patients deemed unsuitable for VKA - Apixiban 5mg po BID vs ASA
Committee make-up
INTERNIST
GASTROENTEROLOGIST
ER PHYSICIAN
HEMATOPATHOLOGIST
HEMATOLOGIST
NEPHROLOGIST
NEUROLOGIST
CARDIOLOGIST
FAMILY PHYSICIAN
• Why is there discordance between guideline committees & specialists when the data is based on the same 3 landmark trials?• Values influence guideline committees and prescribing.• Patient values need to be considered as well; shared
decision making.• Tailor therapy to individual patients.