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Published on: February 26, 2013
Clinical Discussions in Antithrombotic Therapy Management in Patients With Atrial Fibrillation: A Delphi Consensus
Nicola Mumoli1, Claudia Amellone2, Gianfranco Antonelli3
1Department of Internal Medicine, Magenta Hospital, Magenta, Milan, Italy.
Insights
Direct-acting oral anticoagulants (DOACs) are widely used, but clinical practice shows uncertainty in specific patient groups. Further consensus is needed for optimal use of DOACs in elderly, fragile, and comorbid individuals.
Area of Science:
- Cardiology
- Pharmacology
- Internal Medicine
Background:
- Direct-acting oral anticoagulants (DOACs) are increasingly used for stroke prevention in atrial fibrillation and venous thromboembolism.
- Clinical trials have not fully addressed uncertainties regarding DOAC use in real-world patient scenarios.
Purpose of the Study:
- To establish consensus on the use of DOACs in non-valvular atrial fibrillation patients through a Delphi process.
- To address specific clinical uncertainties related to DOAC application in diverse patient populations.
Main Methods:
- A Delphi consensus process involving 101 physicians (cardiologists, internists, geriatricians, hematologists) from Italy.
- Physicians rated agreement on 9 key topics concerning DOAC use using a 5-point Likert scale.
- Consensus was defined as agreement among at least 66% of respondents.
Main Results:
- The study identified areas of uncertainty regarding DOAC application in clinical practice.
- Specific topics included comparisons with vitamin K antagonists, use in elderly and hyperfiltering patients, drug interactions, and management of specific complications like left atrial appendage thrombosis.
- Physician agreement levels varied across the discussed statements.
Conclusions:
- Significant uncertainty persists in the clinical application of DOACs.
- Particular challenges exist in managing elderly, fragile, comorbid, and hyperfiltering patients on DOACs.
- Further guidance and consensus are needed for optimal real-world DOAC utilization.
Background:
In recent years, direct-acting oral anticoagulants (DOACs) have entered clinical practice for stroke prevention in non-valvular atrial fibrillation or prevention and treatment of venous thromboembolism. However, remaining uncertainty regarding DOAC use in some clinical scenarios commonly encountered in the real world has not been fully explored in clinical trials.
Methods:
We report on use of a Delphi consensus process on DOAC use in non-valvular atrial fibrillation patients. The consensus process dealt with 9 main topics: (i) DOACs vs vitamin K antagonists in atrial fibrillation (AF) patients; (ii) therapeutic options for patients with stable total time in range treated with vitamin K antagonists; (iii) therapeutic options for patients aged > 85 years; (iv) therapeutic management of hyperfiltering patients; (v) pharmacologic interactions; (vi) therapeutic options in the long-term treatment (prevention) of patients with AF and acute coronary syndrome after the triple therapy; (vii) low doses of DOACs in AF patients; (viii) ischemic stroke in patients inappropriately treated with low doses of DOACs; (ix) management of patients taking DOACs with left atrial appendage thrombosis.
Results:
A total of 101 physicians (cardiologists, internists, geriatricians, and hematologists) from Italy expressed their level of agreement on each statement by using a 5-point Likert scale (1 = strongly disagree; 2 = disagree; 3 = somewhat agree; 4 = agree; 5 = strongly agree). Votes 1-2 were considered to be disagreement; votes 3-5 were considered to be agreement. Agreement among the respondents of ≥ 66% for each statement was considered consensus. A brief discussion of the results for each topic is also reported.
Conclusions:
In clinical practice, there is still uncertainty on DOAC use, especially in elderly, fragile, comorbid, and hyperfiltering patients.
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