Clinical conundrums in antithrombotic therapy management: A Delphi Consensus panel

Area of Science:

• Cardiology
• Hematology
• Clinical Pharmacology

Background:

• Anticoagulants are crucial for preventing stroke in atrial fibrillation (AF) and treating venous thromboembolism (VTE).
• Clinical trials often exclude complex patient groups (e.g., severe bleeding, renal impairment, frailty), leading to management variability.
• Expert consensus can bridge the gap between guidelines and real-world practice for challenging cases.

Purpose of the Study:

• To investigate expert consensus on managing challenging AF and VTE patient scenarios.
• To identify areas of agreement and divergence in anticoagulant therapy for complex cases.
• To explore strategies for improving guideline adherence in real-world settings.

Main Methods:

• A modified-Delphi method was employed with 178 Italian specialists in AF and VTE.
• A questionnaire assessed the appropriateness of anticoagulant therapy in specific challenging clinical situations.
• Included scenarios involved low CHA2DS2-VASc scores, comorbidities, frailty, and varying VTE risk levels.

Main Results:

• All 178 experts completed the questionnaire, indicating high engagement.
• Consensus was achieved on numerous challenging AF and VTE cases.
• Uncertainty persists for specific debated topics ('conundrums') lacking robust clinical evidence.

Conclusions:

• Expert-derived indications can guide the management of difficult AF and VTE cases.
• Further clinical studies are necessary for scenarios where expert consensus was not reached.
• Addressing treatment gaps in complex patient populations is essential for improving outcomes.