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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">It was with considerable interest that we read the article by Guedes et al&#46; on the HIPOGAIA study&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> which in 2014 studied 479 patients with non-valvular atrial fibrillation &#40;AF&#41; under oral anticoagulation with vitamin K antagonists &#40;VKAs&#41; in primary health care and revealed a moderate degree of pharmacodynamic control using these drugs&#44; with a mean time in therapeutic range &#40;TTR&#41; of 67&#46;4&#37;&#46; A third of patients were inadequately controlled &#40;mean TTR &#60;60&#37;&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The results are interesting&#44; but they need to be put into context in view of changes in prescribing patterns of oral anticoagulants &#40;OACs&#41; in Portugal&#44; particularly of the novel oral anticoagulants &#40;NOACs&#41;&#44; also known as non-vitamin K antagonist oral anticoagulants&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">NOACs were approved for non-valvular AF prior to the HIPOGAIA study&#44; and three &#40;apixaban&#44; rivaroxaban and dabigatran&#41; have been reimbursed by the state healthcare system for this indication since August 2014&#44; the period covered by the study&#46; Their added therapeutic value&#44; based on convenience and safety&#44;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2&#8211;4</span></a> together with a safety profile at least non-inferior to warfarin&#44; make these drugs an attractive option for patients without contraindications&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Consequently&#44; a substantial proportion of patients have been prescribed NOACs from the start&#44; while others have changed from VKAs to NOACs&#44; particularly those with poor INR control&#46; This means that the population of patients taking VKAs is increasingly a selected one&#44; which may partly explain the results of the HIPOGAIA study&#44; such as the high rate of patients with low TTR in hospital outpatient clinics&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Evidence that NOACs are now the first-line OACs in Portugal&#44; as recommended in the European Society of Cardiology guidelines on AF&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> is provided by data on prescription of these drugs &#40;independently of therapeutic indication&#41; from INFARMED&#44; the Portuguese Health Authority&#44; and the health consultants IMS Health&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Between 2010 and the first quarter of 2016&#44; the use of NOACs increased&#44; as measured by the number of packages and of defined daily doses &#40;DDDs&#41;&#44; a standard measure established by the World Health Organization to assess drug prescribing and dispensing&#46; The peak of VKA use was in 2014&#44; since when it has fallen &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Besides this change in prescribing patterns&#44; the overall quantity of OACs prescribed has risen significantly &#40;a good sign considering that they had previously under-prescribed<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a>&#41;&#44; mainly due to increased use of NOACs&#46; In the first quarter of 2016&#44; the latter already dominated the market in OACs&#44; with 58&#46;4&#37; of packages sold and 51&#46;1&#37; of DDDs &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The era of NOACs has arrived in Portugal&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">DC received a grant from <span class="elsevierStyleGrantSponsor" id="gs1">Funda&#231;&#227;o para a Ci&#234;ncia e Tecnologia &#40;FCT&#41;</span> - SFRH&#47;SINTD&#47;96409&#47;2013 - Bolsa Interno-Doutorando&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">DC and JJF have no conflicts of interest to declare&#46; FJP is a consultant for Astra Zeneca&#44; Bayer and Boehringer Ingelheim&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Caldeira D&#44; Ferreira JJ&#44; Pinto FJ&#46; A era dos novos anticoagulantes orais em Portugal&#46; Rev Port Cardiol&#46; 2017&#59;36&#58;577&#8211;578&#46;</p>"
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