Do patients with atrial fibrillation (AF) need to remain on a Direct Oral Anticoagulant (DOAC) indefinitely?

Indefinite DOAC Therapy is Required for Atrial Fibrillation with Elevated Stroke Risk

Patients with atrial fibrillation and elevated thromboembolic risk (CHA₂DS₂-VA score ≥2) should remain on DOAC therapy indefinitely unless contraindications develop or alternative stroke prevention strategies are implemented. 1

Determining Need for Lifelong Anticoagulation

Risk Assessment

• Anticoagulation decisions are based on CHA₂DS₂-VA score:
  • Score ≥2: Oral anticoagulation strongly recommended (Class I, Level A) 1, 2
  • Score of 1: Oral anticoagulation should be considered (Class IIa, Level C) 1
  • Patients with hypertrophic cardiomyopathy or cardiac amyloidosis require anticoagulation regardless of score 1

Duration of Therapy

• The 2024 ESC guidelines clearly indicate that anticoagulation for AF is not a time-limited therapy but rather a lifelong intervention for patients with ongoing stroke risk 1
• Regular reassessment of thromboembolic risk is recommended, not to discontinue therapy but to ensure appropriate patients are receiving anticoagulation 1

DOAC Selection and Management

First-Line Therapy

• DOACs are recommended over vitamin K antagonists (VKAs) for stroke prevention in AF (Class I, Level A) 1, 2
• DOACs provide at least non-inferior efficacy compared to warfarin with 50% reduction in intracranial hemorrhage 2
• Meta-analysis shows DOACs reduce:
  • Stroke/systemic embolism (HR 0.81)
  • All-cause mortality (HR 0.90)
  • Intracranial bleeding (HR 0.48) 2

Important Considerations

• Avoid inappropriate dose reduction of DOACs (Class III, Level B) 1
• DOACs are contraindicated in:
  • Mechanical heart valves
  • Moderate-to-severe mitral stenosis
  • Severe renal impairment (CrCl <15 mL/min) 2
• Switching between DOACs without clear indication is not recommended (Class III, Level B) 1

Special Situations

Bleeding Management

• If bleeding occurs, temporarily interrupt anticoagulation until cause is identified and resolved 1
• Specific antidotes should be considered for life-threatening bleeds 1
• After bleeding is controlled, anticoagulation should be resumed as stroke risk persists

Perioperative Management

• For procedures, DOACs can be temporarily interrupted following a standardized protocol:
  • Low bleeding risk: Omit 1 day before, resume 1 day after
  • High bleeding risk: Omit 2 days before, resume 2-3 days after 3
• This approach is associated with low rates of major bleeding (0.9-1.85%) and arterial thromboembolism (0.16-0.60%) 3

Alternatives to Anticoagulation

• Left atrial appendage occlusion may be considered for patients with contraindications to long-term anticoagulation 1
• Antiplatelet therapy alone is not recommended as an alternative to anticoagulation (Class III, Level A) 1

Impact of Non-Anticoagulation

• Withholding DOAC therapy in eligible AF patients is associated with significantly higher mortality
• A large retrospective cohort study showed DOAC therapy was associated with 31% lower risk of all-cause mortality compared to no anticoagulation (HR 0.69) 4

Common Pitfalls to Avoid

• Inappropriate dose reduction without meeting specific criteria
• Adding antiplatelet therapy to anticoagulation without indication (Class III, Level B) 1
• Discontinuing anticoagulation based solely on bleeding risk scores 1
• Switching between DOACs without clear clinical reason 1
• Assuming paroxysmal AF carries lower stroke risk than persistent/permanent AF 1

In conclusion, for patients with AF and elevated stroke risk, anticoagulation therapy should be maintained indefinitely unless contraindications develop or alternative stroke prevention strategies are implemented. The benefits of continued anticoagulation in preventing stroke and reducing mortality outweigh the risks in most patients with ongoing AF.