🎙️ 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!

Chapters

• 0:20 DOACs: Revolutionary Blood Thinners
• 0:54 When DOACs Are Preferred
• 1:20 Clear DOAC Contraindications
• 2:13 Uncertain Cases Requiring Shared Decision-Making

Transcript

Speaker 1: 0:10

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 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 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 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: 1:44

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: 2:11

End stage renal disease the reason why 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.