In which scenario are DOACs not approved and warfarin is preferred?

• A. Mechanical heart valves
• B. Atrial fibrillation with normal renal function
• C. DVT with CrCl 60
• D. PE with no comorbids

Answer: (A)

Direct oral anticoagulants are used for many conditions, but they are not approved for patients with mechanical heart valves. The prosthetic valve creates a thrombosis risk that requires the well-established, carefully monitored anticoagulation provided by warfarin. Trials testing DOACs in mechanical valve patients did not show safety and efficacy comparable to warfarin, and the guideline recommendation is to use warfarin in this scenario.

In the other scenarios, DOACs are approved and commonly preferred: atrial fibrillation without mechanical valves and with normal renal function, and treatment of DVT or PE in patients with adequate renal function.