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Aims: To estimate the rate of non-vitamin K oral anticoagulant (NOAC) dosing that is lower- and higher-than-recommended and to describe the reasons for NOAC dose discordance with Health Canada prescribing information., Methods: The OPTIMAL AF Programme was an observational cohort quality assessment initiative in which primary and specialty care physicians in eight provinces provided a snapshot of their anticoagulated non-valvular atrial fibrillation (NVAF) patients through either an electronic medical record (EMR) system or standardised, paper-based data collection methods., Results: Data on 1681 NVAF patients receiving oral anticoagulation (OAC) for stroke prevention was provided by 102 physicians. A NOAC was prescribed in 1379 patients (8%). The standard recommended dose was prescribed in 849 (76%) and reduced dose in 264 (24%). Concordance of the reduced dose with Health Canada prescribing information occurred in 154 patients (58%). The standard dose was concordant in 805 (95%). The main reasons for the use of discordant reduced doses were age of 80 years or more, elevated creatinine, prior bleeding or dose recommended by specialist., Discussion and Conclusion: The vast majority of Canadian patients meeting the Canadian Cardiovascular Society (CCS) guideline recommendations for OAC to decrease AF-related stroke risk were receiving product monograph-concordant NOAC dosing (85%). Nonetheless, this highlights the fact that an important proportion of patients were prescribed doses that are discordant and opportunities remain to improve NOAC dosing to optimise stroke prevention., (© 2020 John Wiley & Sons Ltd.)

Competing Interests: Competing interests: Theodore Wein reports receiving grants from Allergan, Boehringer Ingelheim and Bayer, and grants and consulting fees from Servier, Allergan and Ipsen; conducting accredited continuing medical education sessions for Servier; and receiving travel reimbursement from Servier. David Gladstone reports no personal financial relationships with industry in the 36 months prior to publication. He serves as principal investigator of the SCREEN-AF trial (uncompensated; trial funded by the Canadian Stroke Prevention Intervention Network (C-SPIN), which is funded by the Canadian Institutes of Health Research [CIHR]), and as a national co–principal investigator for the Canadian arm of the ARCADIA trial, which is funded by the National Institutes of Health. Dr. Gladstone previously served as an independent medical safety monitor for that trial (uncompensated); principal investigator of a research grant from the CIHR-funded C-SPIN Network for the Ontario Holter/Echo Database; and a local site investigator for NAVIGATE ESUS, and NASPAF-ICH (all site fees paid to institution). Alexandre Poppe is site principal investigator and site co-investigator for NoNo and Bayer and has received a grant from Canadian Stroke Trials for Optimized Results. Alan Bell reports receving personal fees from AstraZeneca Novartis, Pfizer, Servier and Bayer, outside the submitted work. He is the vice-president of Thrombosis Canada (unpaid position), serves on the board of directors of Hypertension Canada (unpaid position) and was an author of the Antiplatelet Guideline of the Canadian Cardiovascular Society. Leanne K Casaubon reports receiving personal fees from Medtronic and Bayer and is site principal investigator for a clinical trial related to NA1 by NoNo Inc. (no personal financial compensation). James Douketis reports receiving personal fees from Leo Pharma, Janssen, Pfizer, Bristol-Myers Squibb, Sanofi, Servier Canada and Portola, which are deposited in hospital-based (St. Joseph’s Healthcare Hamilton) and university-based (McMaster University) research accounts or charitable foundations. Dr. Douketis also reports receiving personal fees as an employee of The Merck Manual and UpTo-Date. Thalia Field reports receiving grants and personal fees from Bayer Canada, and personal fees from Pfizer-BMS and Servier, outside the submitted work. Jeffrey Habert reports receiving personal fees from Pfizer, Amgen, BMS, Bayer, Boehringer Ingelheim, Eli-Lilly, Purdue, Allergan, AstraZeneca, Lundbeck, Novo-Nordisk, Servier, Janssen, Roche, HLS, Otsuka (speaker, advisory board or consulting), and from Alliance, MD-Briefcase, Bausch, Liv, MedPlan, Brandaide, Academy, Bridge, Seacourses, Meducom, the International Centre for Professional Development in Health and Medicine, CPD Network, Antibody, CHRC, STA Healthcare Communications, CTC, Canadian Collaborative Research Network, Four Health Comm (scientific committee, consulting), outside the submitted work. Shamir Mehta reports receiving grants and personal fees from AstraZeneca, grants from Boston Scientific, and personal fees from Bayer. William Semchuk reports receiving personal fees from Bayer, Pfizer, Servier, BMS, Sanofi, and AstraZeneca, outside the submitted work. Mikul Sharma reports receiving grants and honoraria from Bayer, grants from Boehringer Ingelheim and Bristol-Myers Squibb, and consulting fees from Portola and Daiichi Sankyo. Jacob Udell reports receiving grants and personal fees from AstraZeneca, Boehringer Ingelheim, Janssen and Sanofi. Eric E Smith has received personal fees from Portola Pharmaceuticals and Biogen. Dar Dowlatshahi has received a grant from the Heart and Stroke Foundation of Canada and honoraria from Bayer, BMS and Apopharma, outside the submitted work. Gord Gubitz is a member of advisory boards for Bayer, Boehringer Ingelheim and Pfizer. No other competing interests were declared.

The 2017 update of The Canadian Stroke Best Practice Recommendations for the Secondary Prevention of Stroke is a collection of current evidence-based recommendations intended for use by clinicians across a wide range of settings. The goal is to provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations include those related to diagnostic testing, diet and lifestyle, smoking, hypertension, hyperlipidemia, diabetes, antiplatelet and anticoagulant therapies, carotid artery disease, atrial fibrillation, and other cardiac conditions. Notable changes in this sixth edition include the development of core elements for delivering secondary stroke prevention services, the addition of a section on cervical artery dissection, new recommendations regarding the management of patent foramen ovale, and the removal of the recommendations on management of sleep apnea. The Canadian Stroke Best Practice Recommendations include a range of supporting materials such as implementation resources to facilitate the adoption of evidence to practice, and related performance measures to enable monitoring of uptake and effectiveness of the recommendations. The guidelines further emphasize the need for a systems approach to stroke care, involving an interprofessional team, with access to specialists regardless of patient location, and the need to overcome geographic barriers to ensure equity in access within a universal health care system.

Acetylsalicylic acid (ASA) is no longer recommended for primary prevention in individuals without a history of symptomatic cardiovascular disease, stroke or peripheral artery disease; the harms of daily ASA use could potentially outweigh the benefits. Important questions remain, including benefits of ASA for younger high-risk patients, individuals with subclinical vascular disease and asymptomatic atherosclerosis, and outcomes in patients who cease taking ASA after long-term use for primary prevention. Current use of ASA or anticoagulants was an exclusion criterion in all trials; however, 36% of participants in the ASCEND trial[4] had used ASA before screening, while 11% had used ASA previously in the ASPREE trial.[3] Median duration of follow-up ranged from 4.7 to 7.1 years. In a meta-analysis of pooled individual patient data from 10 RCTs,[21] the risk of cardiovascular events associated with the use of 75-100 mg ASA for primary prevention decreased with increasing weight, while low-dose ASA had the greatest preventive effect among those participants weighing 50-69 kg. [Extracted from the article]