Indications for Warfarin Over Direct Oral Anticoagulants (DOACs)

Primary Indications for Warfarin

The American College of Cardiology recommends warfarin as the only anticoagulant for patients with mechanical heart valves, as DOACs are contraindicated in this population 1, 2, 3
The American College of Cardiology suggests that patients with moderate to severe mitral stenosis should receive warfarin rather than DOACs 4, 5, 3
Valvular atrial fibrillation, defined as AF with moderate to severe mitral stenosis or mechanical heart valves, requires warfarin therapy, according to the American College of Cardiology and Stroke guidelines 2, 5

The American College of Cardiology recommends that INR should be checked at least weekly during initiation of warfarin therapy and at least monthly when anticoagulation is stable 1, 4
The target INR range for most indications is 2.0-3.0, though higher targets (INR 2.5-3.5) may be appropriate for mechanical heart valves, as suggested by the American College of Cardiology and Stroke guidelines 2, 3

The American College of Cardiology notes that warfarin may be a safer option for patients on certain cancer therapies that have significant interactions with DOACs 6

The American College of Cardiology acknowledges that warfarin remains significantly less expensive than DOACs, which may be an important consideration for patients with limited financial resources or inadequate insurance coverage 1, 5

The American College of Cardiology advises assessing for drug-drug and drug-food interactions when prescribing warfarin, as these can significantly affect INR stability 1, 4
Regular monitoring is essential with warfarin therapy to maintain therapeutic INR and reduce complications, according to the American College of Cardiology 1, 5
For patients with non-valvular atrial fibrillation, DOACs are generally preferred over warfarin due to superior safety profiles and at least equivalent efficacy, as recommended by the American College of Cardiology 4, 5