ACC clarifies when DOACs should—and shouldn’t—be used

Clinical takeaway: Reassess every DOAC patient for the right indication, agent, dose, duration, bleeding risk, renal/hepatic function, interactions, adherence, and affordability—because underuse and inappropriate dosing remain common despite strong evidence.

A new ACC Scientific Statement synthesizes established and emerging evidence on direct oral anticoagulants (DOACs) for preventing and treating thrombotic events, emphasizing practical implementation across atrial fibrillation (AF), venous thromboembolism (VTE), cancer-associated thrombosis, stroke, left atrial appendage closure (LAAC), AF ablation, and high-risk populations.

For AF, DOACs remain preferred over warfarin for most patients, except those with moderate-to-severe rheumatic mitral stenosis or mechanical valves. Routine DOAC use after transcatheter aortic valve implantation is not recommended unless another anticoagulation indication exists. In chronic coronary disease with an anticoagulation indication, DOAC monotherapy at regular dosing is reasonable long term; in selected high-risk CAD or PAD patients without full-dose anticoagulation needs, rivaroxaban 2.5 mg twice daily plus low-dose aspirin may reduce MI, stroke, and cardiovascular death.

For acute VTE, DOACs are recommended for most patients, with apixaban highlighted as a potential agent of choice after recent data showed lower clinically relevant bleeding than rivaroxaban. Extended anticoagulation beyond 6 months should be considered for unprovoked, recurrent, or high-recurrence-risk VTE; options include apixaban 2.5 mg or 5 mg twice daily, rivaroxaban 10 mg daily, or dabigatran 150 mg twice daily. Aspirin alone offers limited protection.

In cancer-associated thrombosis, DOACs or LMWH may be used, but DOACs are generally preferred because of lower VTE recurrence and similar major bleeding risk. Apixaban has the strongest evidence base, including reduced-dose apixaban 2.5 mg twice daily after 6 months for extended therapy, with similar efficacy and lower bleeding risk versus 5 mg twice daily.

Special population guidance favors apixaban in frailty and in many patients at high bleeding risk; rivaroxaban or apixaban in class 3 obesity; avoiding dabigatran in dialysis; and selecting DOACs by Child-Pugh class in liver disease, with rivaroxaban avoided in Child-Pugh B and all DOACs unsupported in Child-Pugh C.

“This statement is intended to complement existing clinical practice guidelines by synthesizing evolving data, clarifying areas of uncertainty, and supporting individualized, patient-centered decision making,” the writing committee said.

Source: Kumbhani DJ, et al. (2026 June 30) J Am Coll Cardiol. Direct Oral Anticoagulants in Primary and Secondary Prevention of Thrombotic Events: 2026 ACC Scientific Statement: A Report of the American College of Cardiology