Bejjani A, Khairani CD, Assi A, et al. When Direct Oral Anticoagulants Should Not Be Standard Treatment: JACC State-of-the-Art Review. J Am Coll Cardiol. 2024 Jan 23;83(3):444-465. doi: 10.1016/j.jacc.2023.10.038. (Systematic review)

For most patients, direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists for stroke prevention in atrial fibrillation and for venous thromboembolism treatment. However, randomized controlled trials suggest that DOACs may not be as efficacious or as safe as the current standard of care in conditions such as mechanical heart valves, thrombotic antiphospholipid syndrome, and atrial fibrillation associated with rheumatic heart disease. DOACs do not provide a net benefit in conditions such as embolic stroke of undetermined source. Their efficacy is uncertain for conditions such as left ventricular thrombus, catheter-associated deep vein thrombosis, cerebral venous sinus thrombosis, and for patients with atrial fibrillation or venous thrombosis who have end-stage renal disease. This paper provides an evidence-based review of randomized controlled trials on DOACs, detailing when they have demonstrated efficacy and safety, when DOACs should not be the standard of care, where their safety and efficacy are uncertain, and areas requiring further research.

Discipline Area Score
Hemostasis and Thrombosis 6 / 7
Neurology 6 / 7
Internal Medicine 6 / 7
Cardiology 6 / 7
Comments from MORE raters

Cardiology rater

This review summarizes the evidence for and against DOAC use under specific circumstances where they may not be as useful.

Cardiology rater

The article evaluates the efficacy and safety of DOACs against standard treatments, focusing on areas where DOACs should not be the first choice and where evidence regarding their use remains uncertain. It employs a systematic review of RCTs and observational studies to assess the efficacy and safety of DOACs across various conditions. The review used a standard statistical analysis, offering a robust examination of available DOAC usage in different scenarios. The heterogeneity among patient populations is acknowledge and subgroup analyses were done. The review authors also acknowledges the variability in study designs, populations, and outcomes, with detailed reporting. It covers a range of clinical scenarios and patient subgroups, providing a broad perspective on DOAC use. The conclusions are based on recommendations that are grounded in research. It also addresses practical concerns about DOAC use in real-world clinical settings, making it highly relevant for practitioners.

Hemostasis and Thrombosis rater

Figure 1 is useful from a practical point of view.

Internal Medicine rater

Definitely relevant. Most might not know this.

Internal Medicine rater

Figure 1 is a nice comparison chart that puts this into clinical perspective.

Internal Medicine rater

This is a very important paper. Because DOACs have become the standard of care for many patients with AF, we tend to reflexively use them over warfarin in many situations where they are either inferior or not proven better.

Internal Medicine rater

The authors comprehensively covered the evidence-based literature on DOAC therapy in atrial fibrillation and venous thromboembolism. They acknowledged limitations in using direct oral anticoagulants for thrombotic events in the presence of antiphospholipid syndrome, rheumatic atrial fibrillation, and mechanical prosthetic valves. They also discussed medical conditions where the benefits and risks of direct oral anticoagulant therapy remain uncertain. This review holds significant clinical relevance.

Neurology rater

Very good summary of current literature and good exposition of current uncertainty.
Comments from EvidenceAlerts subscribers

No subscriber has commented on this article yet.