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Expert Review

Proper Use of Anticoagulants for Stroke Prevention in Atrial Fibrillation

Cardiology

Chapter 1: Stroke Prevention in Atrial Fibrillation: The Guidelines

Gustavo Saposnik, MD MPH FRCPC
Associate Professor of Neurology
HSF Canada Career Scientist
Director, Outcomes Research & Decision Neuroscience Unit
St Michael’s Hospital, University of Toronto
Toronto, Ontario

In the setting of atrial fibrillation (AF), anticoagulation significantly reduces the risk of stroke. Yet, studies have shown repeatedly that AF patients have not received appropriate anticoagulation whether the goal is primary or secondary prevention. The problems have included failure to place AF patients on any anticoagulation, failure to employ a therapeutic dose, and failure of patients to adhere to their prescription. Understanding the reasons for the disappointing adherence to guidelines provides an opportunity to reverse an ongoing source of preventable mortality and morbidity. The goal of this program will be to emphasize the risk of stroke in patients with AF and clarify the evidence-based strategies for the proper management of AF patients whether preventing a first stroke or recurrent strokes. With greater adherence to proper use of anticoagulation, a substantial reduction in preventable morbidity and stroke-related death can be anticipated.

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Chapter 2: Strokes in an Era of Effective Prevention

Theodore Wein, MD
Assistant Professor of Neurology and Neurosurgery
McGill University
Montreal, Quebec

In Canada, about one fifth of ischemic strokes are attributed to atrial fibrillation (AF). Of stroke causes, AF-associated stroke is considered one of the most preventable. The benefit of the vitamin K antagonist warfarin has been clearly established in multiple large clinical trials and subsequent trials with non-vitamin K antagonist oral anticoagulants (NOACs) have shown a similar benefit associated with a lower risk of bleeding. The problem is that these drugs are underutilized at least in part due to fear of inducing bleeding. The guidelines for use of oral anticoagulants are relatively simple and evidence-based, but studies show that these agents are frequently withheld or NOACs are used in reduced dosages to avoid risk of bleeding. Modified dosing is appropriate in a few well-defined subgroups, but due to the devastating consequences of major strokes, the benefit-to-risk ratio favors full doses of NOACs in the majority of AF patients who are candidates for stroke prevention.

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Chapter 3: Practical Considerations for Oral Anticoagulants in Stroke Prevention

Ashkan Shoamanesh, MD
Associate Professor, Division of Neurology
McMaster University
Hamilton, Ontario

Non-vitamin K antagonist oral anticoagulants (NOACs) are often not employed in recommended or adequate doses for stroke prevention in patients with atrial fibrillation (AF). Largely attributed to fear among clinicians of inducing bleeding events, this suggests there is an incomplete understanding of the major opportunity these agents provide for risk reduction. In almost all patients, benefit-to-risk ratio from stroke prevention is favorable. When compared to warfarin, the four available NOACs have demonstrated similar or superior efficacy in pivotal trials. The modest differences amongst the NOACs in safety relative to warfarin and in pharmacokinetics relative to each other are relevant to dosing or choice of NOAC in some patients. Recognizing the importance of anticoagulation in AF patients and the principles of appropriate therapy provides an important opportunity to reduce an important source of morbidity and mortality in Canada.

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Disclaimer

The information and opinions expressed herein are those of the participants and do not necessarily reflect those of Xfacto Communications Inc. or the sponsor. The distribution of this meeting report was made possible through industry support under written agreement that ensures editorial independence. The content is for educational purposes and should not be taken as an endorsement of any products, uses or doses. Physicians should consult the appropriate monograph before prescribing any drugs. Distribution, reproduction, alteration of this program is strictly prohibited without written consent of Xfacto Communications Inc. Copyright 2020. All rights reserved. The Medical XchangeTM

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