Perception of physicians on factors that influence the choice of a dicoumarin or a new oral anticoagulant in patients with non-valvular atrial fibrillation

Abstract

Aims Recent studies have demonstrated the efficacy and safety of new oral anticoagulant drugs for the prevention of thromboembolic events in patients with non-valvular atrial fibrillation. Our aim was to evaluate the factors that can influence physicians in their choice between a classic and a new anticoagulant in these patients. Design Several variables of interest were discussed and analysed using a WorkmatTM methodology. Sites Six regional meetings were held in Spain (East, Catalonia, Andalusia-Extremadura, Madrid, North-east, and North of Spain). Participants Meetings were attended by 39 specialists (cardiologists, neurologists, haematologists, internists, and emergency and Primary Care physicians). Measurements Each participant graded their level of agreement, with a score from 1 to 10, on every analysed variable. Results A new anticoagulant drug was preferred in patients with previous failure of dicoumarin therapy (9.7 ± 0.5), high haemorrhagic risk (8.7 ± 1), prior bleeding (7.8 ± 1.5), and high thrombotic risk (7.7 ± 1.2). Dicoumarins were preferred in cases of severe (1.2 ± 0.4) or moderate (4.2 ± 2.5) kidney failure, good control with dicoumarins (2.3 ± 1.5), cognitive impairment (3.2 ± 3), and low haemorrhagic risk (4.3 ± 3). Age, sex, weight, cost of drug, polymedication, and low thrombotic risk achieved intermediate scores. There were no differences between the different specialists or Spanish regions. Conclusions The presence of a high thrombotic or haemorrhagic risk and the failure of previous dicoumarin therapy lead to choosing a new oral anticoagulant in patients with non-valvular atrial fibrillation, while kidney failure, cognitive impairment, good control with dicoumarins, and a low bleeding risk predispose to selecting a classic dicoumarin anticoagulant.

Objetivo: Estudios recientes han demostrado la eficacia y la seguridad de los nuevos anticoagulantes orales (NACO) en la prevención de tromboembolias en pacientes con fibrilación auricular no valvular (FANV). Nuestro objetivo es evaluar qué factores influyen en los médicos para elegir entre dicumarínicos o NACO. Diseño: Se analizaron distintas variables, que fueron discutidas y puntuadas siguiendo una metodología Workmat®. Emplazamiento: Se realizaron 6 reuniones regionales en España (Levante, Cataluña, Andalucía-Extremadura, Madrid, Noroeste y Norte de España). Participantes: Participaron 39 especialistas (cardiólogos, neurólogos, hematólogos, internistas y médicos de urgencias y atención primaria). Mediciones: Cada participante puntuó de 1 a 10 (de menor a mayor) el grado de acuerdo con cada variable analizada. Resultados: Se elegiría preferiblemente un NACO en pacientes con fracaso previo del tratamiento dicumarínico (9,7±0,5), riesgo hemorrágico elevado (8,7 ±1) antecedentes de hemorragia (7,8±1,5) y riesgo trombótico alto (7,7±1,2). Se decantarían por un dicumarínico en casos de disfunción renal grave (1,2±0.4) o moderada (4,2±2,5), buen control con dicumarínicos (2,3±1,5), deterioro cognitivo (3,2±3) y riesgo hemorrágico bajo (4,3±3). La edad, el sexo, el peso, el coste del fármaco, la polimedicación y la existencia de un riesgo trombótico bajo obtuvieron puntuaciones intermedias. Conclusiones: El riesgo trombótico y hemorrágico elevado y el fracaso del tratamiento previo con dicumarínicos predisponen a elegir un NACO. La insuficiencia renal, el deterioro cognitivo, el buen control con dicumarínicos y un riesgo hemorrágico bajo inclinan a decantarse por un dicumarínico clásico