[New operative models for the management of anticoagulant prophylaxis]

Anticoagulant therapy has proven to be effective for patients at risk for thromboembolic disease. Nevertheless, in daily clinical practice the oral anticoagulant therapy (OAT) is underused because it is still considered dangerous and difficult to manage, particularly in patients with chronic non-rheumatic atrial fibrillation. In the most important published studies about this topic we found that only 7-55% of patients with atrial fibrillation were treated with antiplatelet drugs, while 9.9-48.4% took anticoagulant prophylaxis; so, despite a favourable temporal trend after large trials have shown a positive prophylactic effect with antithrombotic drugs, they are underused. It has been estimated that in our country 500,000-600.00 potential patients could have indication for this treatment. Nevertheless, the traditional management of oral anticoagulation is fraught with difficulties such as patients' compliance, reliability of laboratory, global management of the treatment. Undoubtedly, this prophylaxis is very heavy for the patient and the physician often don't like this treatment for its dangerous potential, frequent difficulties of the management, obstacles in the communication among laboratory, physician and patient. Other common problems usually are the distance from patient's home-laboratory, its working hours, means of transportation. It is important a suitable organization and a control of the factors contributing to obtain favourable results for assuring a good cost/benefit ratio of OAT. The relationship among patient-physician-laboratory play a fundamental role. Alternative models are therefore prospected: anticoagulation clinic, computerised decision support software or portable coagulometer. Actually available instruments give us immediately the patients' INR and represent a new option and a promising strategy to monitor these large cohort of patients. Thus the management of OAT can be done by family physicians or by anticoagulant clinic or by patients themselves, after a suitable training period permitting a partial or total self management. These new strategies have improved therapeutic control of oral anticoagulation and in addition to the health advantages both also have economic benefits.