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CardioNerds co-founder Dr. Amit Goyal, series co-chair Dr. Colin Blumenthal, and episode lead Dr. Anushka Tandon to discuss pharmacologic anticoagulation options in atrial fibrillation with Drs. Ashley Lochman and Chris Domenico. The case-based review helps clarify some key concepts, such as when warfarin is preferred for anticoagulation, who may be a good DOAC (direct-acting oral anticoagulant) candidate, how to choose an appropriate DOAC agent, and how to manage anticoagulation therapy in patients already on antiplatelet therapies. Notes were drafted by Dr. Anushka Tandon. The episode audio was edited by student Dr. Shivani Reddy.\n\n\n\nThis CardioNerds Atrial Fibrillation series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs,\xa0Dr. Kelly Arps\xa0and\xa0Dr. Colin Blumenthal.\n\n\n\nThis episode was planned and recorded prior to the release of the 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Please refer to this guideline document for the most updated recommendations.\n\n\n\nWe have collaborated with VCU Health to provide CME. Claim free CME here!\n\n\n\n\n\n\n\n\n\n\n\nCardioNerds Atrial Fibrillation PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll\n\n\n\n\n\nCardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!\n\n\n\n\n\n\n\n\n\nPearls and Quotes - Anticoagulation Pharmacology\n\n\n\n\nAvoid potentially fatal errors with this terminology tip for correctly referencing non-warfarin oral anticoagulant agents: it\u2019s DOAC (like, please DO use AntiCoagulation), not NOAC (imagine someone interpreting that as \u201cNO AntiCoagulation for this patient\u201d at discharge \u2013 yikes)!\n\n\n\nSometimes, an oldie really is a goodie \u2013 warfarin is recommended over DOACs for patients with mechanical heart valves, moderate-to-severe mitral stenosis, anti-phospholipid antibody syndrome (APLS), left ventricular (LV) thrombus, higher INR goals, or DOAC failure. Patient preference and medication costs should also be considered \u2013 at the end of the day, \u201cthe best drug is the drug that a patient is willing to take!\u201d\n\n\n\nStandard-dose rivaroxaban or apixaban may be considered for use in patients weighing >120kg or with BMI >40; use of other DOACs should be limited to pts weighing =/< 120kg or with BMI =/< 40.\n\n\n\nThe pharmacists involved in this podcast promise they don\u2019t have stock in apixaban! It just often happens to be the preferred DOAC option in certain scenarios \u2013 think patients with severe renal impairment (including ESRD) or with an increased risk for bleeding events (including older adults, those with a history of GI bleed, etc).\n\n\n\nIn general, dual therapy (DOAC or warfarin + P2Y12 inhibitor) is non-inferior to triple therapy (oral anticoagulant + P2Y12 inhibitor + aspirin) at preventing thrombotic events but is associated with a lower risk of bleeding events. Most patients can be transitioned to dual therapy after 7-30 days on triple therapy post-percutaneous coronary intervention.\n\n\n\nWhat\u2019s that on the horizon? Factor XI inhibitors may become the breakout stars of anticoagulation \u2013 multiple investigational agents are being studied for their potential to reduce thrombotic risk without significantly increasing bleeding risk in patients with indications for anticoagulation therapy\u2026at least that\u2019s the theorize hope. Watch this space!\n\n\n\n\nNotes - Anticoagulation Pharmacology\n\n\n\nIn which cases is warfarin preferred over DOACs in patients with atrial fibrillation?\n\n\n\n\nLong-term anticoagulation with warfarin is indicated in patients with atrial fibrillation and either a mechanical valve or moderate-to-severe mitral stenosis (i.e., valvular atrial fibrillation as defined in the 2019 AHA/ACC/HRS guidelines on atrial fibrillation [1]). The REALIGN trial [2] showed increased rates of thromboembolic and bleeding complications with dabigatran vs.