🎙️ Episode 42: DOACs Decoded: When to Dabble, When to Dodge

🧠 Clinical Context

DOACs (Direct Oral Anticoagulants) have revolutionized anticoagulation—goodbye routine INRs, hello convenience. But while they’ve made our lives easier, they’re not always a fit for every scenario. Here's how to navigate the DOAC jungle.

✅ When DOACs Are Preferred

• Venous Thromboembolism (VTE)
• Atrial Fibrillation
  • ⚠️ Exclude patients with:
    • Mechanical heart valves
    • Rheumatic mitral valve disease
       (That’s why cardiologists note “non-rheumatic” AF in their documentation—treatment plan hinges on it.)

⛔ When DOACs Are a No-Go

• Mechanical Heart Valves → Warfarin only
• Rheumatic AF → Warfarin still rules
• Thrombotic Antiphospholipid Syndrome → Warfarin
• Transcatheter Aortic Valve Replacement (TAVR) → Antiplatelet therapy
• Embolic Stroke of Undetermined Source → Antiplatelets preferred

🤔 The Gray Zone: Uncertain Use Cases

These aren’t absolute yes or no. Instead, cue shared decision-making and expert input:

• Pregnancy
  • No strong evidence yet; avoid unless discussed with OB and hematology.
• End-Stage Renal Disease (ESRD)
  • Initially excluded from DOAC trials.
  • Some are doing well, but still a case-by-case basis.
• Others That Require Discussion:
  • Left Ventricular Thrombus
  • Catheter-Associated DVT
  • Splanchnic Vein Thrombosis
  • Cerebral Venous Thrombosis

🧩 Clinical Takeaway

DOACs are game-changers—but they’re not plug-and-play for everyone. For classic AF and VTE? Go for it. For valves, rheumatic disease, or complex syndromes? Tread carefully. And when in doubt, involve the patient in the decision.

🎯 Bottom line: Not every clot deserves a DOAC—some still want warfarin or a platelet plan.

Let me know when you're ready for the next one!

Transcript

Speaker 1 0:00

Now let's talk about DOACs . We know they've been evolutionary , revolutionary and they make life a lot easier . Just think about it whenever you have a patient with warfarin

DOACs: Revolutionary Blood Thinners

Speaker 1 0:10

and having to make sure that you're getting those numbers right Now . Are DOACs perfect ? No , do they help out a lot ? Yes , and they make life a little bit easier for all of us and they also help patients out . But let's try to identify when are DOACs preferred and when we should be thinking about it and when should we stop them . Now . Conditions for when DOACs are preferred Venous thromboembolism . Now atrial fibrillation excluding the patients with the mechanical heart valves , or rheumatic atrial fibrillation . Now if you notice and you're

When DOACs Are Preferred

Speaker 1 0:44

looking at your cardiology friend's notes , they're talking about a lot of times they'll put in atrial fibrillation . Now if you notice and you're looking at your cardiology friends notes we look at they're talking about a lot of times we'll put an atrial fibrillation and put non-rheumatic . The purpose is the treatment plan is going to be different , so it's . That's why they do that . You may always wonder why they may say rheumatic or non-rheumatic atrial fibrillation in their notes . Now , when are doax and no-go ? When should never use them ? This is due to our current evidence Mechanical heart valves . Never use them . Warfarin Rheumatic

Clear DOAC Contraindications

Speaker 1 1:10

atrial fibrillation warfarin that's why when you look at those cardiology notes , they put rheumatic versus non-rheumatic . It helps you in the treatment plan . Thrombotic antiphospholipid syndrome you're goingine is warfarin . Now , transcatheter aortic valve replacement use antiplatelet therapy Embolic stroke of undetermined source antiplatelet therapy .

Speaker 1 1:34

Now we have a full lecture on DOACs . If you choose to go through it , it's in our brilliant board prep . It's very helpful and it's most up to date with all the related information in dox , because dox are newer in the scene and there's still a lot of information , still a lot of studies to be done on them . Now , what is it on ? Cert and this isn't saying that you shouldn't use them , but maybe this is a shared decision making pregnancy no great studies right now .

Speaker 1 2:01

End stage renal disease the reason why

Uncertain Cases Requiring Shared Decision-Making

Speaker 1 2:03

this is here and this is changing , it's a shared decision-making . Well , this was because the studies excluded end-stage renal disease . Now are people with end-stage renal disease on DOACs and doing ? Well , yes , they are . So this becomes a shared decision-making . Same thing with these is there's not great studies and these have continued workup and these are complexities . When you look at these , these have a lot of complexities to them and we need to figure out why they're having them , and it's almost a shared decision-making maybe also with expert decision-making too is left ventricle thrombus , catheter-associated deep thrombosis , splanchnic vein thrombosis and cerebral venous thrombosis . These ones would need more of a discussion . It also needs shared decision-making with the person who's receiving these the patient themselves and or the patient's power of attorney , or the person that they're using to trust to make their decisions for them , because there's not slam dunks either way on the decision-making for these .