Switching from Warfarin to a DOAC for Atrial Fibrillation

Patient Assessment

The European Society of Cardiology recommends that patients with non-valvular atrial fibrillation and a high CHA₂DS₂-VASc score, such as this patient with age ≥75, hypertension, and diabetes, should be considered for anticoagulation therapy 1
The American College of Cardiology states that patients with a bioprosthetic valve, such as a TAVR, are eligible for DOAC therapy, unlike those with mechanical heart valves 2
The European Heart Journal notes that the absence of mechanical heart valves or moderate-to-severe mitral stenosis makes this patient a suitable candidate for DOAC therapy 1, 2

The European Society of Cardiology recommends DOACs over vitamin K antagonists like warfarin in eligible patients with atrial fibrillation to prevent stroke and thromboembolism, with a 50% reduction in intracranial hemorrhage risk 1, 2
The American College of Cardiology states that meta-analyses show DOACs reduce the risk of stroke or systemic embolism, all-cause mortality, and intracranial bleeding compared to warfarin 1

The European Heart Journal suggests that dose adjustment is necessary for DOACs based on age ≥80 years or other specific criteria, such as renal function 1, 5
The European Society of Cardiology recommends dose reduction for apixaban to 2.5 mg twice daily if the patient meets two of three criteria: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥133 mmol/L 1

The American College of Cardiology notes that renal function should be evaluated before initiating DOAC therapy, as dose adjustments may be required based on creatinine clearance 2
The European Heart Journal states that patients with a bioprosthetic valve, such as a TAVR, are compatible with DOAC therapy 2, 6
The European Society of Cardiology recommends evaluating potential drug interactions between the selected DOAC and the patient's current medications, such as diltiazem 7

The European Heart Journal notes that patients with a TAVR still require antibiotic prophylaxis for dental procedures, regardless of which anticoagulant they take 8

The journal Blood states that specific reversal agents are available for DOACs, such as idarucizumab for dabigatran, and andexanet alfa for factor Xa inhibitors, in case of bleeding 9
The European Society of Cardiology recommends that DOACs can be temporarily discontinued without bridging therapy for planned procedures, unlike warfarin which often requires bridging with heparin 9

The European Heart Journal warns that underdosing DOACs is not recommended unless patients meet specific criteria for dose reduction, as this can lead to inadequate stroke prevention 1
The American College of Cardiology notes that abrupt discontinuation of warfarin without proper transition to a DOAC could leave the patient temporarily unprotected from thromboembolism 5