Clinical Discussions in Antithrombotic Therapy Management in Patients With Atrial Fibrillation: A Delphi Consensus Panel

Abstract

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.

Efficacy and Safety of Antithrombotic Therapy With Oral Anticoagulants in Real-World Elderly Patients With Acute Coronary Syndrome and Atrial Fibrillation

“…Therefore, greater efforts to improve the prescription of OACs in the elderly are necessary, especially among older subjects with ACS and AF. It was recommended by consensus that a short course of dual therapy with OAC and an antiplatelet agent (preferably P2Y 12 ) should be considered as a preferred antithrombotic strategy in the therapeutic process of patients with both ACS and AF ( 9 , 33 ), and OAC should be applied in the long term of the patients' antithrombotic procedure ( 9 ). In our study, we found that even after a long-term follow-up of 5 years, OACs could still safely reduce mortality in elderly patients with both ACS and AF.…”

Efficacy and safety of oral anticoagulants in elderly patients with stable coronary artery disease and atrial fibrillation

“…Recent guidelines recommended that a short course of dual therapy with OAC and an antiplatelet agent (preferably P2Y12) should be considered as a preferred antithrombotic strategy in the therapeutic management of patients with both ACS and AF [ 8 , 34 ]. However, no guidelines have been published for OACs in patients with SCAD and AF [ 8 , 35 ].…”

Efficacy and safety of oral anticoagulants in elderly patients with stable coronary artery disease and atrial fibrillation

“…Recent guidelines recommended that a short course of dual therapy with OAC and an antiplatelet agent (preferably P2Y12) should be considered as a preferred antithrombotic strategy in the therapeutic management of patients with both ACS and AF [5,31]. However, no guidelines have been published for OACs in patients with SCAD and AF [5,32].…”