Clinical conundrums in antithrombotic therapy management: A Delphi Consensus panel

INTERNATIONAL JOURNAL OF CARDIOLOGY

卷:249

Article

Colonna, Paolo¹  Andreotti, Felicita²  Ageno, Walter^3,4  Pengo, Vittorio⁵  Marchionni, Niccola^6,7,8 

[1] Policlin Bari Hosp, Cardiol Dept, Piazza G Cesare, I-70124 Bari, Italy

[2] Catholic Univ, Dept Cardiovasc Med, Rome, Italy

[3] Univ Insubria, Dept Clin & Expt Med, Varese, Italy

[4] Osped Circolo Varese, Varese, Italy

[5] Padua Univ Hosp, Dept Cardiac Thorac & Vasc Sci, Padua, Italy

[6] Univ Florence, Dept Clin & Expt Med, Florence, Italy

[7] Univ Florence, Div Gen Cardiol, Florence, Italy

[8] AOU Careggi, Florence, Italy

关键词: Atrial fibrillation;    Venous thromboembolism;    Anticoagulation therapy;    Factor Xa Inhibitors;    Non-vitamin K antagonist oral anticoagulant;    Consensus conference;    Delphi method;   

DOI  :  10.1016/j.ijcard.2017.09.159

来源: Elsevier

【 摘 要 】

Background: Anticoagulants are recommended for the prevention of stroke/systemic embolismfor most patients with atrial fibrillation (AF) and for the treatment of patients with venous thromboembolism (VTE). Regulatorydriven 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 themanagement 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. Method: 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 CHA(2)DS(2)-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. Results: 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. Conclusions: 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. (C) 2017 The Authors. Published by Elsevier Ireland Ltd.

【 授权许可】

Free