Stroke Prevention in Atrial Fibrillation through Anti-thrombotics: A White Paper on Optimization of Quality and Access to Care.pdf
Canadian Council for Stroke Prevention in Patients with Atrial
Fibrillation advocates for improved access to current and evolving
TORONTO, Dec. 11, 2012 /CNW/ - According to a recently released white
paper, warfarin, the current standard of care for the prevention of
stroke in patients with atrial fibrillation (AF), is suboptimally used
resulting in preventable strokes.
Presented by the Canadian Council for Stroke Prevention in Patients with
Atrial Fibrillation (CC-SPAF), an independent multidisciplinary
advisory council, the white paper offers three recommendations for
preventing stroke in the 200,000 to 600,000 Canadians living with AF1. The paper suggests that the traditional use of treatments such as
warfarin, while effective, come with many challenges.
Specifically, the Council concluded that where appropriate, the
following recommendations to improve the use of anti-thrombotic
therapies to prevent strokes in patients with AF should be considered:
Ensure that appropriate systems and infrastructures are in place for
effective anti-coagulation management.
Publically reimburse all anti-thrombotic therapies approved for SPAF for
Promote awareness of AF and its optimal treatment through professional
societies and advocacy groups to lead to better outcomes.
Improved systems for managing anti-thrombotic therapies and better
access and awareness of easier to manage treatment alternatives, such
as the novel oral anti-coagulants (NOACs), could prevent the often
fatal and disabling outcomes for Canadians who suffer an AF-related
stroke. With AF expected to triple in frequency over the next four
decades2, the Council advises that there is an urgent need to improve access to
these new, potentially life-saving treatments and calls for greater
awareness of AF and advocacy to address the issue. The Council also
cites the importance of having appropriate systems and infrastructures
in place for effective anti-coagulation management.
"Despite the ability of warfarin to reduce the risk of stroke in AF by
two-thirds and risk of death by one-quarter, patients with AF often
face hurdles when it comes to how the treatment affects their quality
of life," says Dr. Mike Sharma, Chair, CC-SPAF and Director, Champlain
Regional Stroke Program, The Ottawa Hospital. "The process can be
cumbersome; it involves routine blood monitoring that is often
inconvenient to the patient and costly for the healthcare system."
Research has shown that because of the limitations of warfarin fewer
than 50 per cent of patients eligible for warfarin are prescribed the
treatment3, resulting in a large untreated population. Furthermore, of those
patients prescribed warfarin, fewer than half are appropriately
anti-coagulated4, revealing that warfarin treatment remains sub-optimal for patients
To address rising healthcare costs and to optimize patient care and
stroke prevention in AF, the CC-SPAF's white paper explores the
importance of increasing awareness of AF as well as other oral
therapies for preventing stroke due to AF. Compared to warfarin, NOACs
offer predictable dose responses, eliminate the need for monitoring of
the blood thinning effect and have virtually no dietary interactions,
thereby greatly improving patients' quality of life. Furthermore,
clinical trials comparing NOACs with warfarin have demonstrated
efficacy and safety advantages for patients5.
AF is the most common cardiac rhythm disturbance and a leading cause of
stroke in Canada; a deceiving fact considering that a large proportion
of AF patients are undiagnosed6. Twenty per cent of Canadians with AF who suffer stroke die within one
year and 60 per cent are left with a significant neurologic disability3. As Canada's population continues to age, AF is projected to almost
triple in frequency over the next four decades2; for this reason, greater awareness of AF is needed.
The increasing prevalence of AF will lead to an even more costly
healthcare system if action is not taken. Strokes cost the Canadian
economy $2.7 billion per year7 and it is estimated that, in the six-month period following a new
stroke, the direct and indirect healthcare costs for new stroke
patients add up to an average of $50,0008.
"NOACs could offer an important cost-effective treatment for those who
are either not on warfarin, or for those who are inadequately managed
while taking it," says Dr. Tammy Bungard, Director, Anticoagulation
Management Service (AMS), Alberta Health Services, Edmonton, Alberta
and Associate Professor of Medicine, Division of Cardiology, University
of Alberta. "For optimal outcomes, professionals must be able to
choose the appropriate treatment. A significant part of choice is
having all approved anti-coagulants publicly reimbursed. This
reimbursement would represent a major move forward in the prevention of
AF-related stroke by easing the burden of AF on an already strained
About Atrial Fibrillation (AF)
Atrial fibrillation (AF) is the most common sustained heart rhythm
abnormality. An estimated 200,000-600,000 Canadians are affected by AF1 and this number continues to rise due to the aging population.
AF is marked by an irregular and often rapid heart rate that commonly
causes poor blood flow to the body and is a major risk factor for
ischemic stroke and death. AF predisposes patients to the formation of
a blood clot in the heart, which can break away and then become trapped
in blood vessels in the brain, causing a stroke. There are
approximately 50,000 hospital admissions due to stroke per year; of
these, 15 per cent are estimated to be associated with AF9. Strokes occurring as a result of AF tend to be more devastating to
patients. Twenty per cent of AF patients who suffer stroke die within
one year and 60 per cent are left with a neurologic disability3.
About the Canadian Council for Stroke Prevention in Patients with Atrial
The Canadian Council for Stroke Prevention in Patients with Atrial
Fibrillation (CC-SPAF) is an independent multidisciplinary advisory
council established to provide advice, insight and guidance to policy
makers and other stakeholders (such as patient advocacy groups and
health professionals) across Canada.
Members of the Council include:
Mike Sharma, MD MSc FRCPC, Director, Champlain Regional Stroke Program, The Ottawa
Dean Ast, BSP, Pharmacy Practice and Policy Consultant
Alan Bell, MD CCFP, Assistant Professor, Department of Family and Community
Medicine, University of Toronto
Tammy J. Bungard, BSP PharmD, Director, Anticoagulation Management Service (AMS),
Alberta Health Services, Edmonton, Alberta and Associate Professor of
Medicine, Division of Cardiology, Faculty of Medicine and Dentistry,
University of Alberta
Alexis Dishaw, Director, Community and Patient Transition and Allied Services, Humber
River Regional Hospital (Vice-Chair)
John Eikelboom, MBBS MSc FRCPC, Associate Professor, Division of Hematology and
Thromboembolism, Department of Medicine, McMaster University
Vidal Essebag, MD PhD FRCPC FACC, Director of Cardiac Electrophysiology, McGill
University Health Centre
Theresa Green, RN PhD, Assistant Professor, Faculty of Nursing, University of Calgary
Gerry Jeffcott, Health and Pharmaceutical Policy Consultant
Janet McTaggart, Executive Director, Stroke Survivors Association of Ottawa
Harry Zwanenburg, MD MHA, Health Care Consultant
For more on the Council's recommendations, please see the link to the
white paper below.
The Council was supported by an unconditional grant from Bayer Inc.,
however it retained full freedom to reach its own conclusions and
communicate its views.
1 As found in: Kerr CR et al., Report from the Canadian Cardiovascular Society Consensus Conference:
Atrial Fibrillation 2004, accessed at http://www.ccs.ca/download/CCS_Consensus_Report.pdf on Nov. 29, 2011;
Stroke and AF, What is AF?, accessed at http://www.strokeandaf.ca/AF-and-stroke/what-is-af.aspx on Dec. 4, 2011;
Heart and Stroke Foundation of Canada, Heart Disease Conditions: Atrial Fibrillation, accessed at http:// www.heartandstroke.com/site/c.ikIQLcMWJtE/b.5052135/k.2C86/Heart_disease__Atrial_fibrillation.htm on Dec. 4, 2011;
Dewar RI and Lip GYH, Identification, diagnosis and assessment of atrial
fibrillation, Heart 2007: 93: 25-28. accessed at http://heart.bmj.com/content/93/1/25 extract on Dec. 4, 2011;
Kirchhof P et al., Outcome parameters for trials in atrial fibrillation:
executive summary. Recommendations from a consensus conference
organized by the German Atrial Fibrillation Competence NETwork (AFNET)
and the European Heart Rhythm Association (EHRA). European Heart
Journal 2007: 28: 2803-2817;
Wiesel J et al., Detection of Atrial Fibrillation Using a Modified
Microlife Blood Pressure Monitor, American Journal of Hypertension,
2009, Vol. 22, 848-852.
2 As found in: Go AS et al., Prevalence of diagnosed atrial fibrillation
in adults: national implications for rhythm management and stroke
prevention: the Anticoagulation and Risk Factors in Atrial Fibrillation
(ATRIA) Study, Journal of the American Medical Association, 2001: 285:
Miyasaka Y et al., Secular trends in incidence of atrial fibrillation in
Olmsted County, Minnesota, 1980 to 2000, and implications on the
projections for future prevalence, Circulation. 2006: 114: 119-125.
3 Gladstone DJ et al., Potentially Preventable Strokes in High-Risk Patients with Atrial
Fibrillation who are not Adequately Anticoagulated, Stroke. 2009: 40: 235-240
4 Bungard TJ et al., Adequacy of anticoagulation in patients coming to
hospital with atrial fibrillation, Pharmacotherapy, 2000: 20:
5 Ahrens I et al., What do the Re-LY, AVERROES and ROCKET AF trials tell us for stroke
prevention in atrial fibrillation, Thrombosis and Haemostasis 105.4/2011.
6 Kamel H et al., Delayed Detection of Atrial Fibrillation after Ischemic
Stroke, Journal of Stroke and
Cerebrovascular Diseases, 2009: Vol. 18, No. 6: 453-457.
7 Heart and Stroke Foundation of Nova Scotia, Stroke Statistics, accessed at http://www.heartandstroke.ns.ca/site/c.otJYJ7MLIqE/b.3669321/k.BD5A/Stroke_Statistics.htm on Nov. 29, 2011.
8 Sharma M et al., Costs of an ischemic stroke patient in Canada: 6 month costs, Abstract from the 1st Canadian Stroke Congress, Stroke 2010: 41: e473-e510.
9Heart and Stroke Foundation of Canada, Heart Disease Conditions: Atrial
Fibrillation, accessed at http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.5052135/k.2C86/Heart_disease__Atrial_fibrillation.htm on Dec. 4, 2011
PDF available at: http://stream1.newswire.ca/media/2012/12/11/20121211_C8032_DOC_EN_21812.pdf
SOURCE: Canadian Council for Stroke Prevention in Patients with Atrial Fibrillation
For further information:
Canadian Council for Stroke Prevention in Patients with Atrial Fibrillation