Consensus is Possible: Initiation and Exchange of Oral Anticoagulants in Non-valvular Atrial Fibrillation, According to a Territorial Protocol in a Period of Time

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Received date
15 December 2017
Accepted date
15 December 2017
European Cardiology Review 2017;12(2):92–111.

Topic: 1. Clinical Cardiology



Universal use of Direct Oral Anticoagulants (DOACs) in non-valvular atrial fibrillation (nVAF) is not possible for economic reasons. It is necessary to prescribe them to those patients with greater potential benefit. The best way to achieve this objective is the application of a territorial protocol, designed and accepted by all professionals involved in nVAF.


To review the degree of compliance with a territorial, prospective and controlled protocol on anticoagulation in nVAF over a period of time, according to the indications of DOACs and acenocoumarol.

Materials and Methods

A multidisciplinary team of 12 professionals involved in the nVAF process (family medicine, cardiology, neurology, internal medicine, hematology, emergency medicine, hospital and community pharmacy) developed a territorial protocol for a population of 400,000, which is reviewed each 6 months. Prescriptions and follow-ups were centralized in the hemostasis consultation. An ACCES database was designed ad hoc for the introduction of all data.


In a period of 13.5 months (03/01/16 to 04/14/17), a total of 1142 events related to anticoagulation were performed in 1063 patients. Of the prescribed treatments, 96.8 % were adjusted to the protocol. Nine hundred and fourteen patients were on initiation therapy. According to protocol, 717 patients started acenocoumarol and 197 (21.6 %) DOACs (mainly in peri-cardioversion and CHADS 4 patients without chronic ACO indication). In addition, in 228 cases already treated, the anticoagulant treatment was changed one or more times (187 treated with acenocoumarol started DOACs due to poor INR control, intolerance or complications; 11 patients receiving DOACs switched to acenocoumarol, and finally 30 patients already treated with DOACs exchanged drug or dose). In the set of this population and time, 373 patients (35.1 %) are under treatment with DOACs.


A rigorous compliance of a territorial protocol can be achieved when it is duly agreed by all the professionals involved and centralized its follow-up. We are convinced that it is the way to achieve maximum efficiency in addition to having the knowledge of the reality itself. Although a third of the patients are being treated with DOACs, their prescription due to poor INR control should still be improved.