When Direct Oral Anticoagulants Should Not Be Standard Treatment: JACC State-of-the-Art Review

J Am Coll Cardiol. 2024 Jan 23;83(3):444-465. doi: 10.1016/j.jacc.2023.10.038.


For most patients, direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists for stroke prevention in atrial fibrillation and for venous thromboembolism treatment. However, randomized controlled trials suggest that DOACs may not be as efficacious or as safe as the current standard of care in conditions such as mechanical heart valves, thrombotic antiphospholipid syndrome, and atrial fibrillation associated with rheumatic heart disease. DOACs do not provide a net benefit in conditions such as embolic stroke of undetermined source. Their efficacy is uncertain for conditions such as left ventricular thrombus, catheter-associated deep vein thrombosis, cerebral venous sinus thrombosis, and for patients with atrial fibrillation or venous thrombosis who have end-stage renal disease. This paper provides an evidence-based review of randomized controlled trials on DOACs, detailing when they have demonstrated efficacy and safety, when DOACs should not be the standard of care, where their safety and efficacy are uncertain, and areas requiring further research.

Keywords: arterial thrombosis; bleeding; direct oral anticoagulants; randomized controlled trial; standard of care; venous thromboembolism.

Publication types

  • Review

MeSH terms

  • Administration, Oral
  • Anticoagulants / therapeutic use
  • Atrial Fibrillation* / complications
  • Atrial Fibrillation* / drug therapy
  • Humans
  • Randomized Controlled Trials as Topic
  • Thrombosis* / drug therapy
  • Venous Thromboembolism* / drug therapy
  • Venous Thrombosis* / drug therapy
  • Vitamin K


  • Anticoagulants
  • Vitamin K