Delphi consensus on oral anticoagulation management in special clinical situations in the cardiology setting

<b>Background:</b> Management of oral anticoagulation (OAC) can be challenging, such as in complex cases of nonvalvular atrial fibrillation (NVAF). <b>Materials &amp; methods:</b> A Delphi study comprising two rounds was used for gathering expert opinion through an online questionnaire (83 items grouped in 8 dimensions) on OAC management in specific clinical settings. <b>Results:</b> Consensus was reached for 79 items (95%) in round 1. Experts recommended direct-acting oral anticoagulants (DOACs) for pericardioversion, uninterrupted OAC for catheter ablation, and dual therapy with a DOAC and clopidogrel after percutaneous coronary intervention. They also recommended restarting OAC with a DOAC after an intracranial haemorrhage. <b>Conclusion:</b> The expert-based recommendations obtained may contribute to standardizing and guiding the management of OAC in complex clinical situations in cardiology. The ACOPREFERENCE 2 project was a Delphi study to gather opinions from national experts regarding the management of anticoagulation in special clinical situations of nonvalvular atrial fibrillation patients in the cardiology setting. The study involved an expert scientific committee comprised of cardiologists, and a geographically dispersed Delphi expert panel who provided individual and anonymous feedback through an iterative process involving two survey rounds. The Delphi questionnaire included 83 items grouped in eight dimensions regarding the management of anticoagulation in specific clinical settings. Direct-acting oral anticoagulant (DOAC) therapy is the preferred option for stroke prevention in different clinical scenarios such as cardioversion, catheter ablation, percutaneous coronary intervention (PCI), bleeding, and after an intracranial hemorrhage. The panel consistently supported the use of DOAC therapy for stroke risk management prior to cardioversion. Experts recommended performing catheter ablation without interruption of the oral anticoagulant (vitamin K antagonists or DOAC). Following PCI, dual-antithrombotic therapy, including a DOAC and a P2Y₁₂ inhibitor, preferably clopidogrel, emerged as an effective and safe alternative to triple therapy. In accordance with the latest European guidelines, the panel discouraged DOAC therapy in patients with mechanical heart valves. Availability of the dabigatran reversal agent idarucizumab was clearly seen as an advantage for the urgent need to reverse the anticoagulant effect of DOAC therapy in perioperative management and bleeding complications. Dabigatran appears to be better accepted by clinicians and patients due to the availability of idarucizumab.

<b>背景：</b> 口服抗凝治疗（oral anticoagulation, OAC）的管理颇具挑战，例如非瓣膜性心房颤动（nonvalvular atrial fibrillation, NVAF）的复杂病例。<b>材料与方法：</b> 本研究采用两轮德尔菲研究（Delphi study）设计，通过在线问卷（涵盖8个维度、共83个条目）收集针对特定临床场景下OAC管理的专家意见。<b>结果：</b> 第一轮调研中，79个条目（占比95%）达成共识。专家建议对心脏复律患者使用直接口服抗凝药（direct-acting oral anticoagulants, DOACs），导管消融术中持续口服抗凝治疗，以及经皮冠状动脉介入治疗后采用直接口服抗凝药联合氯吡格雷的双联抗栓方案；同时建议颅内出血后重启直接口服抗凝治疗。<b>结论：</b> 本研究获得的基于专家共识的推荐意见，有助于规范并指导心脏病学领域复杂临床场景下的OAC管理。ACOPREFERENCE 2项目是一项德尔菲研究，旨在收集全国专家针对心脏病学场景下非瓣膜性心房颤动患者特殊临床情况的抗凝管理意见。本研究由心脏病学家组成专家科学委员会，以及地理分布广泛的德尔菲专家小组，通过两轮迭代调研流程收集匿名的个体反馈。德尔菲问卷涵盖8个维度、共83个条目，聚焦特定临床场景下的抗凝管理。直接口服抗凝药（DOAC）疗法是不同临床场景下卒中预防的首选方案，包括心脏复律、导管消融、经皮冠状动脉介入治疗（percutaneous coronary intervention, PCI）、出血事件及颅内出血后管理。专家小组一致支持在心脏复律前采用DOAC疗法进行卒中风险管理。专家建议导管消融术中无需中断口服抗凝治疗（维生素K拮抗剂或DOAC均可）。经皮冠状动脉介入治疗后，包含DOAC与P2Y₁₂抑制剂（优选氯吡格雷）的双联抗栓疗法，被证实是三联疗法的安全有效替代方案。参照最新欧洲指南，专家小组不建议机械心脏瓣膜患者使用DOAC疗法。达比加群的特异性逆转剂依达赛珠单抗（idarucizumab）的可及性，被明确视为围手术期管理及出血并发症中快速逆转DOAC抗凝效应的核心优势。由于依达赛珠单抗的存在，达比加群更受临床医师与患者的认可。