See everything is very simple. There will never be head-to-head trials, so you will say Dabigatran is superior, what is the data. The data will never come, so selection of this agent is very simple. If you have a patient who has a high ischemic risk and a low bleeding risk when the ischemic Chad Score is high, bleeding risk is plus/minus you will use Dabigatran in higher dose. Because Dabigatran 150 mg has the greatest power of reducing stroke. So, high ischemic risk, low bleeding, Dabigatran 150 mg. If you have a high ischemic risk and high bleeding because the most of the bleeding risk and the ischemic risk factors are same, then we will use Apixaban. Because Apixaban, the bleeding risk is minimal. The efficacy is just like warfarin (13:00). Or if Apixaban is not available, you may use Dabigatran 110 mg. Dabigatran 110 mg stroke risk is same, bleeding is less. Suppose you have renal failure, obviously you are going to use Apixaban. If you have GI bleed, we will bank upon Apixaban. If you have MI is the pseudo risk actually the number of MI has never been, whole two or three MI were there, but the number of patients who develops intracerebral hemorrhage 50% of them are dead, so where is the question of MI. Some nominal numerical increase was there, but somebody and CAD is not a contraindication of this. If somebody is scared, he can use Apixaban. Rivaroxaban does not increase MI. If your bleeding risk is very high CHAD score 3, 4, 5, Rivaroxaban has been tested in that patient. Elderly, Apixaban because they are bleeding prone, they have renal failure, so this is how it can be easily selected, although there are no head-to-head, but this is a very rationale and a logical conclusion which you can draw (14:00). Suppose my patient comes with severe renal failure, I am not going to use Dabigatran, I am not going to use, I will straight off use Apixaban. If the patient has high bleeding, high ischemia, I will use Apixaban. Even in absence of head to head trial, you can easily choose the agent and you can also reply why I am choosing it. It is not that elderly, I will Apixaban, I will not use.
We have the data, why using Apixaban because the bleeding is risk, GI bleed, why using Apixaban, Dabigatran increases the GI bleeding so that is why I am using and then GI bleed is easily manageable for all practical purposes. Unlike the head bleed intracranial, you will die. So, disadvantage with Dabigatran and Rivaroxaban, they increased GI, but Apixaban does not increase. To some extent it may decrease it.
So, definitely, as Dr. Manoria has said very well that he has given very practical kind of the approach as to how the VKAs are available, but they have very wide kind of practical issues like monitoring of INR, PT monitoring, food drug interaction (15:00) and poor compliance and the NOACs can replace that and even out of all three NOACs how each and every NOAC can be selected for single individual kind of patient, renal failure, high GI bleed and MI patients, so it is very well answered by Dr. Manoria.