Vitamin K antagonists in the era of direct oral anticoagulants: is there still a room for their use?

Excerpt

According to the most recent guidelines on the management of venous thromboembolism (VTE) and atrial fibrillation (AF), direct oral anticoagulants (DOACs) became the mainstay of prevention and treatment of thromboembolic and cardio-embolic complication [1, 2]. A number of randomized controlled trials (RCTs) and meta-analyses have clearly shown that DOACs are at least as effective and safe as vitamin K antagonists (VKAs) in these settings [3‐6]. Furthermore, DOACs’ use has been associated with a significant and clinically important reduction of the risk of intracranial bleeding [3, 5, 6]. It is commonly believed that patients enrolled in RCTs are highly selected not representative of true clinical practice [7]. However, in DOACs’ case, real world data substantially confirmed results of RCTs suggesting a net clinical benefit associated with this therapy over VKAs [8‐10]. Outside the environment of the RCT, DOACs’ use leads to a higher absolute risk of thromboembolic and hemorrhagic events. Nonetheless, several large retrospective and prospective cohort studies report a real risk of these complications in the “real world” scenario [8‐10]. …