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Background: Atrial fibrillation (AF) is associated with a high risk of stroke and other thrombo-embolic events and their prevention relies on antithrombotic therapy, at present mainly with vitamin K antagonists (VKA). The aim of this study was to provide an overall picture on the extent to which current recommendations on oral anticoagulation (OAC) therapy with VKA in AF correspond to actually prescribed OAC in an unselected, real world, population of consecutive patients with AF in Italy. Secondary objective was to assess the rate of "optimal" anticoagulation., Methods: Sixty-three cardiology units located in different geographic areas of Italy enrolled a total of 2046 outpatients with nonvalvular AF (54% males and 46% females, age 73.3±10.2 years)., Results: OAC with VKAs was prescribed in 1394 (68%) of patients and was progressively more frequent on going from paroxysmal (46%) to persistent (71%) and permanent AF (78%)(P<0.001). A high prescription rate (88%) occurred in patients with CHA2DS2-VASc >2. In patients with CHA2DS2-VASc=0 and HAS-BLED<3, still 59% were on OAC, whereas in 33% of patients with CHA2DS2-VASc ≥2 and HAS-BLED<3, OAC therapy was not prescribed. In patients with CHA2DS2-VASc ≥2 and HAS-BLED>3, the preference was towards OAC prescription. 66% of patients were at target for INR., Conclusions: The ISPAF study shows that in an Italian population of real world patients with AF adherence to current guidelines on OAC therapy based on stroke-risk scoring system is rather high, although rate of prescription should be increased. However, contrary to recommendations, in a high proportion of low-risk patients OAC therapy is still prescribed, and this might expose patients to unjustified risks., (© 2013.)

Oral anticoagulant therapy (OAT) with vitamin K antagonists significantly reduces thromboembolic risk in patients with atrial fibrillation (AF), but is associated with increased hemorrhagic risk. In older patients, despite a higher hemorrhagic risk, the net clinical benefit is in favor of OAT. In clinical practice, however, underuse of OAT and suboptimal quality control, with unsatisfactory INR time in therapeutic range, are frequently reported. This is particularly true in older patients with AF, despite the fact that they are at higher risk of thromboembolic events. New oral anticoagulants (NOAs) are represented by direct thrombin inhibitors (dabigatran) or direct Xa factor inhibitors (rivaroxaban, apixaban). In phase III studies, NOAs have shown at least a non-inferiority to warfarin in thromboembolic risk reduction in AF patients and are also associated with a reduction in life-threatening bleedings, in particular intracranial bleedings. In addition, NOAs are administered in daily fixed doses and do not require regular INR monitoring. For all these reasons, NOAs will likely replace warfarin in the elderly in the next future.