Even with robust evidence demonstrating their efficacy and safety, direct oral anticoagulants (DOACs) continue to be underused and, at times, inappropriately dosed, particularly in patients at elevated thrombotic risk. A new ACC Scientific Statement published in JACC provides evidence-based guidance on the use of DOACs in primary and secondary prevention of thrombotic events.

Recommendations

The Scientific Statement offers a comprehensive overview of key guideline recommendations, as well as established and emerging indications for DOAC therapy. Consensus recommendations are provided for the specific use of DOACs for primary prevention of venous thromboembolism (VTE) and stroke; management and secondary prevention of VTE; and secondary prevention after acute stroke, left atrial appendage closure, and atrial fibrillation (AFib) ablation.

Special Patient Populations

Additionally, the Statement also addresses DOAC management in special patient populations, including those with chronic kidney disease, liver disease, frailty, obesity or prior bleeding. Guidance is also included for patients with cancer-associated thrombus. Across the board, "practical considerations such as drug selection, dosing strategies, duration of therapy, bleeding risk assessment, management of anticoagulant-related bleeding, drug–drug interactions, adherence, and cost-related barriers to care" are also noted.

"This statement is intended to complement existing clinical practice guidelines by synthesizing evolving data, clarifying areas of uncertainty, and supporting individualized, patient-centered decision making," according to the Writing Committee, chaired by Dharam J. Kumbhani, MD, SM, FACC. "... By addressing both evidence and implementation challenges, this document aims to improve the appropriate and equitable use of DOACs across the spectrum of thrombotic disease."