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Atrial Fibrillation Stroke Prevention
with Oral Anticoagulants
Why is there discordance between guideline committees
& spe...
January 2013
April 2015
CCS AF Guidelines
• 2010:
• Dabigatran preferred over warfarin
(Conditional Recommendation,
High-Quality Evidence).
• 2012...
CCS AF Guidelines GRADE
2014 Guidelines
AHA/ASA 2014 Stroke Prevention Guidelines
• Prevention of recurrent stroke in patients with non-
valvular ...
2014 Guidelines
AHA/ASA 2014 Stroke Prevention Guidelines
• Prevention of recurrent stroke in patients with non-
valvular ...
Committee make-up
INTERNIST
GASTROENTEROLOGIST
ER PHYSICIAN
HEMATOPATHOLOGIST
HEMATOLOGIST
NEPHROLOGIST
NEUROLOGIST
CARDIOLOGIST
FAMILY
PHYS...
• Why is there discordance between guideline committees
& specialists when the data is based on the same 3
landmark trials...
Cadth 2015 e5 ad panel discussion   af
Cadth 2015 e5 ad panel discussion   af
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Cadth 2015 e5 ad panel discussion af

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Cadth 2015 e5 ad panel discussion af

  1. 1. 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?
  2. 2. January 2013
  3. 3. April 2015
  4. 4. 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
  5. 5. CCS AF Guidelines GRADE
  6. 6. 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)
  7. 7. 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
  8. 8. Committee make-up
  9. 9. INTERNIST GASTROENTEROLOGIST ER PHYSICIAN HEMATOPATHOLOGIST HEMATOLOGIST NEPHROLOGIST NEUROLOGIST CARDIOLOGIST FAMILY PHYSICIAN
  10. 10. • 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.

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