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Warfarin to DOAC Switching Decision — EECC MCQ

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ModerateArrhythmia & ElectrophysiologyWarfarin to DOAC Switching DecisionEECC

A 68-year-old man with AF has been on warfarin for 15 years with a well-controlled time in therapeutic range (TTR) of 82%. His cardiologist discusses switching to a DOAC. Is switching from well-controlled warfarin to a DOAC recommended?

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Correct answer: C — If warfarin TTR is >70% (well-controlled), switching to a DOAC is reasonable but not mandatory; DOACs offer practical advantages (no INR monitoring, fewer food/drug interactions), but well-controlled warfarin has equivalent efficacy

The 2024 ESC AF Guidelines recommend DOACs as first-line over warfarin for most AF patients (Class I). However, patients with well-controlled warfarin (TTR >70%) represent a group where the incremental benefit of switching to DOAC is less clear — subgroup analyses of the landmark DOAC trials (RE-LY, ROCKET-AF, ARISTOTLE, ENGAGE AF) showed that DOACs' superiority over warfarin was most pronounced in centres/patients with lower TTR. For patients with TTR >70%, switching is reasonable but not mandatory, considering: practical advantages of DOACs (no monitoring, predictable kinetics, fewer interactions), patient preference, and cost. Warfarin remains the ONLY option for mechanical heart valves and moderate-severe rheumatic MS.

Reference: ESC (2024): AF Guidelines