Lights and shadows in the management of old and new oral anticoagulants in the real world of atrial fibrillation by italian internists. a survey from the atrial fibrillation registry for ankle-brachial index prevalence assessment-collaborative italian study

Atrial fibrillation (AF) is the most frequent cardiac arrhythmia, which is associated with an enhanced risk for stroke and myocardial infarction [1], [2] and [3]. Vitamin K antagonists (VKAs) have been the golden standard for stroke prophylaxis but they are associated with a significant risk of bleeding [4]. VKAs are unsuitable for many patients, due to difficulties related to the frequent need for check of INR values, or to difficulties in achieving and maintaining an adequate Time in Therapeutic Range (TTR). Non-vitamin K oral anticoagulants (NOACs), inhibiting activated Factor X or prothrombin, represent a valid alternative, as they showed similar efficacy to VKAs with a safer profile [5], without the need for frequent laboratory monitoring [6] and [7]. To investigate the use and the appropriateness of NOACs prescription by Italian internists, we performed a survey among the Internal Medicine Centers (IMCs) from the Atrial Fibrillation Registry for Ankle-Brachial Index Prevalence Assessment-Collaborative Italian (ARAPACIS) study. Among the 136 IMCs involved in the ARAPACIS study, 93 participated in the survey. To each IMC a questionnaire addressing the following points was administered: 1) Prescription of antithrombotic therapy: We asked if the IMC directly prescribes NOACs, or whether it refers to an Oral Anticoagulation Clinic (OAC) or to a cardiologist. Of the 93 IMCs, 59 (63.4%) directly prescribe NOACs, 22 (23.7%) refer to an OAC and 10 (10.8%) to a cardiologist for the management of antithrombotic therapy. Two IMCs (2.1%) do not prescribe NOACs. 2) Choice of antithrombotic treatment: We examined the use of antiplatelet therapy, VKAs or NOACs. Each prescribing IMC was asked to indicate the percentage of patients according to the different treatments. Overall, aspirin was given to 9%, VKAs to 55% and NOACs to 36% of AF patients. 3) Reasons for prescription of NOACs (Fig. 1) Reasons for prescription of NOACs. Fig. 1. Reasons for prescription of NOACs. Figure options a) Low TTR. TTR is inversely correlated with ischemic stroke and bleeding [8]. We asked the prescribing IMCs about the relevance attributed to low TTR (< 60%) in prescribing NOACs. Inadequate TTR had a low, medium and high relevance for 46%, 13.5% and 40.5% of the IMCs, respectively. b) Difficult management of VKAs therapy. We asked the prescribing IMCs about the difficulties in the management of VKC therapy as a reason for switching to NOACs. This issue was of low, medium and high relevance for 44%, 18% and 38% of the IMCs, respectively. c) Patient's preference. Shared decision making with patients should be part of initial evaluation of an antithrombotic therapy [6] and [7]. We asked about the importance of patient's preference in deciding for NOAC therapy. This issue was considered of low, medium and high relevance for 17%, 13% and 70% of the IMCs, respectively. d) Choice of physician. Physicians have a major role in prescribing NOACs. Physician decision was considered of low, medium and high relevance for 19%, 25% and 56% of the IMCs, respectively. 4) Adherence to guidelines in NOACs prescription: AF patients need an accurate initial evaluation when starting an antithrombotic therapy [6] and [7]. A total of 94% of prescriber IMCs use CHAD2DS2-VASc for stroke risk stratification, whereas only 6% did not; 94% of the IMCs state to collect information about patient's therapy in order to avoid drug interferences. Analysis of renal function is evaluated by 94% and liver function by 90% of the IMCs. Moreover, 92% of the IMCs ask for complete blood count before prescription. Another relevant point is clinical follow-up [6]; 53% of the IMCs perform a follow-up at 3–6 and 12 months, 30% at 6–12 months and 17% at 12 months after NOACs prescription. 5) Use of different NOACs: Finally, we asked about NOACs preferences by prescribing IMCs: dabigatran was given in 35%, rivaroxaban in 41% and apixaban in 24% of the cases.