Direct oral anticoagulant: Looking beyond convenience

Abstract

Since the 2010 Food and Drug Administration approval of Dabigatran as the first non-vitamin-K antagonist oral anticoagulants or direct oral anticoagulants (DOACs) as it is now more commonly referred to, there has been much development in the field with increasing availability of different DOACs and an expansion in indications of use. In the prevention of thromboembolism in nonvalvular atrial fibrillation (NVAF), DOACs have overtaken warfarin, which has been first-line therapy since the 1950s. In the most recent 2023 guidelines by the American Heart Association (AHA) for the diagnosis and management of atrial fibrillation, there is a Class 1A recommendation for patients who are candidates for anticoagulation without mechanical heart valve or history of moderate-to-severe rheumatic mitral stenosis to be prescribed DOACs over warfarin to reduce the risk of mortality, stroke, systemic embolism and intracranial haemorrhage.1 This stance is also echoed by the European Society of Cardiology guidelines in 2020,2 and—closer to home—in the Asia Pacific Heart Rhythm Society 2017 Consensus.3