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?

3. January 2013

4. April 2015

5. 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

6. CCS AF Guidelines GRADE

7. 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 CHA 2 DS 2 -VASc score ≥2: Warfarin (1A) Apixaban, dabigatran, rivaroxaban (1B)

9. 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 CHA 2 DS 2 -VASc score ≥2: Warfarin (1A) Apixaban, dabigatran, rivaroxaban (1B) ARISTOTLE, RELY, ROCKET AVVEROES -Patients deemed unsuitable for VKA - Apixiban 5mg po BID vs ASA

10. Committee make-up

11. FAMILY PHYSICIAN CARDIOLOGISTNEUROLOGISTNEPHROLOGISTHEMATOLOGISTHEMATOPATHOLOGISTER PHYSICIANGASTROENTEROLOGISTINTERNIST

12. 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.