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January 2013

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. 2010:

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January 2013

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  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. January 2013

  3. April 2015

  4. 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

  5. CCS AF Guidelines GRADE

  6. 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

  7. 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 2014 Guidelines

  8. Committee make-up

  9. 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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