Is direct oral anticoagulant (DOAC) monotherapy recommended for patients with stable coronary artery disease (CAD)?

From the Guidelines

DOAC monotherapy is not recommended for patients with stable coronary artery disease (CAD). The most recent guidelines from the European Heart Journal, specifically the 2024 ESC guidelines for the management of chronic coronary syndromes 1, suggest that oral anticoagulant (OAC) monotherapy with either vitamin K antagonist (VKA) or rivaroxaban is not recommended in CCS patients without a concomitant long-term indication for OAC. Key points to consider include:

• The COMPASS trial reported no significant ischemic benefit of rivaroxaban monotherapy over aspirin alone, with a significantly higher incidence of modified-ISTH major bleeding 1.
• OAC may be considered in patients who cannot tolerate antiplatelet agents, have a low risk of bleeding, or have a concomitant long-term indication for OAC.
• The standard treatment for stable CAD consists of antiplatelet therapy with aspirin, which targets platelet aggregation, the primary pathophysiological mechanism in atherosclerotic disease and plaque rupture.
• Using DOACs alone in stable CAD patients without other indications for anticoagulation exposes them to unnecessary bleeding risks without providing additional benefit over standard antiplatelet therapy. Some potential scenarios where DOAC monotherapy might be considered in the context of CAD include:
• Patients with a concomitant indication for anticoagulation, such as atrial fibrillation or venous thromboembolism, where the benefits of anticoagulation outweigh the risks.
• Patients who have undergone a period of dual antiplatelet therapy (DAPT) after an acute coronary event or stent placement and are then transitioned to DOAC monotherapy to reduce bleeding risk.

From the Research

DOAC Monotherapy in Stable CAD

• The use of direct oral anticoagulant (DOAC) monotherapy in patients with stable coronary artery disease (CAD) is not widely recommended, as most studies suggest that DOACs are more effective when combined with antiplatelet therapy 2, 3.
• A meta-analysis published in 2021 found that DOACs combined with antiplatelet therapy significantly reduced the rate of major adverse cardiovascular events (MACE) and ischemic stroke in patients with stable CAD, but increased the risk of major bleeding 2.
• Another study published in 2022 found that DOACs had a lower risk of stroke/systemic embolism, intracranial bleeding, and major bleeding compared to warfarin in patients with stable CAD and atrial fibrillation 3.
• However, there is limited evidence on the use of DOAC monotherapy in stable CAD, and most guidelines recommend the use of antiplatelet therapy alone or in combination with oral anticoagulation in these patients 4, 5, 6.

Efficacy and Safety of DOAC Monotherapy

• The efficacy and safety of DOAC monotherapy in stable CAD is not well established, and more studies are needed to determine its effectiveness and safety profile 3.
• A systematic review published in 2003 found that oral anticoagulants with and without antiplatelet therapy reduced cardiovascular complications in patients with established CAD, but increased the risk of bleeding 4.
• Another review published in 2020 discussed the latest evidence and future perspectives in treating patients with coronary artery disease, including the use of newer antiplatelet and direct anticoagulant agents 5.
• A review published in 2019 addressed the antithrombotic options in CAD alone, in atrial fibrillation alone, and in their combination, highlighting the need for careful consideration of the risk of bleeding and ischemic events 6.

Clinical Implications

• The use of DOAC monotherapy in stable CAD should be individualized and based on the patient's risk profile, including the risk of bleeding and ischemic events 2, 3.
• Clinicians should carefully consider the benefits and risks of DOAC monotherapy in stable CAD and discuss the treatment options with patients to determine the best course of therapy 4, 5, 6.