Clinical discussions in antithrombotic therapy management in patients with atrial fibrillation: a delphi consensus panel

Abstract Background In the recent years, direct-acting oral anticoagulants (DOACs) have entered the clinical practice for stroke prevention in non-valvular atrial fibrillation (NVAF) or prevention and treatment of venous thromboembolism (VTE). However, there is uncertainty on DOAC use in some clinical scenarios not fully explored by clinical trials, but commonly encountered in the real world. Methods We report a Delphi Consensus on DOAC use in NVAF patients. The consensus dealt with 9 main topics: (1) DOACs versus vitamin K antagonists (VKAs) in AF patients; (2) Therapeutic options for patients with stable total time in range (TTR) treated with VKA; (3) Therapeutic options for patients aged more than 85 years; (4) Therapeutic management of hyperfiltering patients; (5) Pharmacological interactions; (6) Therapeutic options in the long-term treatment (prevention) of patients with AF and ACS after the triple therapy; (7) Low doses of DOACs in AF patients; (8) Ischemic stroke in patients inappropriately treated with low doses of DOACs; (9) Management of patients taking DOACs with left atrial appendage thrombosis. Results One hundred and one 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). Namely, votes 1-2 were considered as disagreement while votes 3-5 as agreement. Agreement among the respondents of ≥66% for each statement was considered consensus. A brief discussion about the results for each topic is also reported. Conclusions In clinical practice there is still uncertainty on DOACs use, especially in elderly, fragile, comorbid and hyperfiltering patients.