Clinical conundrums in antithrombotic therapy management: A Delphi Consensus panel

Anticoagulants are recommended for the prevention of stroke/systemic embolism for most patients with atrial fibrillation (AF) and for the treatment of patients with venous thromboembolism (VTE). Regulatory-driven randomized trials, however, typically exclude extreme patient scenarios involving, for instance, severe bleeding, ischaemic risk, frailty or renal impairment, despite their common occurrence in clinical practice. Uncertainty in the management of such cases leads to a high degree of variability in therapeutic approaches. Consensus conferences or panels may provide insights and help bridge the gaps that separate clinical guidelines from real-world practice. In the present study, a description of challenging AF and VTE patients was submitted to a large panel of experts to investigate areas of common or divergent management.

A modified-Delphi method was used to obtain consensus among 178 Italian AF and VTE specialists. A questionnaire was sent on the appropriateness of anticoagulant therapy in AF and VTE cases, including CHA₂DS₂-VASc=1, comorbid coronary artery disease, frailty, advanced age, risk of falling, prior haemorrhagic stroke, and low- or intermediate-risk pulmonary embolism. Strategies to improve guideline adherence were also investigated.

All participants completed the questionnaire. Consensus was reached on many, but not all cases, leaving uncertainty on some debated topics (conundrums) where decisions are unsupported by clinical studies or driven by controversial results.

The indications emerging from this large panel of experts may help guide the management of challenging AF or VTE cases. Studies are needed addressing treatment options in those cases for whom no consensus was reached.