Topic: 1. Clinical Cardiology
Universal use of Directs Oral Anticoagulants (DOACs) in non valvular atrial fibrillation (nVAF) is not possible for economic reasons. Therefore, it is mandatory to guarantee their prescription of these drugs in patients theoretically most benefited.
To review indications and results of one territorial, prospective and centralized controlled protocol about the use of DOACs in nVAF.
In November 2010 a multidisciplinary group of 13 professionals evolved in the atrial fibrillation process (primary assistance, internal medicine, cardiology, neurology, hemostasis, hospitality and community pharmacy and administration) elaborated one territorial protocol for an area of 400.000 inhabitants, which is updated every six months. Prescriptions and follow-up are centralized in the Hemostasis clinics, collecting all data in an ACCES data base ad hoc constructed.
Between 2011 and august 2016, 887 patients have been prescribed DOACs with a mean exposition time of 1,55 years. Mean age was 74 ± 12 years, CHADS2 2,3 ± 1,7 and CHA2DS2VASC 3,5 ± 1,9. According to our protocol indications, dabigatran was prescribed in 52,4 % of patients (mean follow up 1,29 years / patient), apixaban in 45,7 % (mean follow up 1,41 years / patient) and rivaroxaban in 1,9 % (mean follow up 2,09 years / patient). The reason for prescriptions were: peri electric cardioversion in patients without indication of chronic anticoagulation (27,3 %), CHADS2 > 4 (27,0 %), poor control of INR in antivitamin K treated patients (22,8 %), embolic/hemorrhagic complications under antivitamin K treatment (15,9 %), miscellany (7,0 %). Complications per 100 patients/year were: ictus + peripheral emboli 1,53, total mortality 4,43, cardiovascular mortality 1,24, major digestive bleeding 0,44, intracranial bleeding 0,87.
Our series shows: 1.- A still a very low index of DOACs prescription by INR control. 2.- It is constituted by very high embolic risk patients (especially if peri electric cardioversion patients were excluded). 3.- The sample and follow up time do not allow to compare our efficacy and security results with clinical trials.
Anticoagulation in atrial fibrillation process is complex and applied many different professionals. We are convinced that a common territorial protocol and an centralized follow up is the best way to reach the maximum efficiency.