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.