A scientific statement from the American Heart Association reviews undertreatment with antithrombotic drugs: not prescribing them, patients not taking them, doses below the label, and clinical situations that leave levels subtherapeutic.
The writing group concludes that undertreatment is common across atrial fibrillation, venous thromboembolism and peripheral artery disease, and that it raises rates of ischaemic stroke, systemic embolism, recurrent thrombosis and death. They link it to overestimation of bleeding risk relative to thrombotic risk, deviation from evidence-based dosing, and unequal access to care. They propose antithrombotic stewardship — structured, multidisciplinary review of who is on what, at what dose — as the response.
This is a narrative statement, not new trial data. Its value is in naming underdosing as a patient-safety problem in its own right, alongside bleeding, which tends to get the attention.
- Check every DOAC dose against the label's dose-reduction criteria, not against a general sense of frailty.
- Ask about missed doses at each review; once-daily and twice-daily regimens have different consequences when doses are skipped.
- Reassess patients with atrial fibrillation who are not anticoagulated, and record the reason when therapy is withheld.
- Consider a pharmacist-led review of anticoagulated patients where your unit has one.
Why it matters
Bleeding fear quietly drives underdosing, and the cost is strokes that do not get traced back to the prescription.
Don't overread it
This is an expert statement summarising existing evidence, not a new trial.
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