I love my work. I have survived and thrived in the trenches of general practice for the past 35 years. I am a “little cheese,” in contrast to the “big cheeses” in large academic centres.
In a CMAJ practice article, Moayedi and colleagues1 state:
The Canadian Cardiovascular Society guidelines indicate a preference for novel oral anticoagulants, such as dabigatran, rivaroxaban or apixaban, over warfarin for patients with nonrheumatic atrial fibrillation.
I reviewed the cited article,2 and in the body of the text there was no unqualified statement that the novel anticoagulants should be used in preference of the warfarin. Instead, the article provides a “conditional recommendation” that “suggests” that when oral anticoagulant therapy is indicated, most patients should receive the novel anticoagulants in preference to warfarin.2
I believe that Moayedi and his colleagues at the University of Toronto have been overly enthusiastic in their endorsement of novel anticoagulants. I do not believe the cited reference2 supports this bias. I have communicated with Dr. Paul Dorion, one of the authors of the CMAJ article,1 several times, and he feels that his enthusiasm is justified.
As a “little cheese” in a smaller community, I rely on CMAJ for honest and untainted guidance in respect of safe medical practice. I ask the authors to review their comments and to perhaps qualify their enthusiasm. I refer the authors to an excellent article in Blood3 that does not express a preference for novel anticoagulants, and to my letter,4 which offers reasons why a “big cheese” may be so enthusiastic.
One may say that these are only words, but they are words that will influence the prescribing practices of thousands of physicians across Canada and potentially put hundreds of thousands of patients at risk. These are important words.