The American College of Cardiology's 2026 scientific statement, published in June, reviews the use of direct oral anticoagulants across atrial fibrillation, venous thromboembolism, special populations, the periprocedural period and after stroke, left atrial appendage closure and ablation.
Its central observation is an implementation gap: DOACs are under-prescribed and sometimes inappropriately dosed, particularly in higher-risk patients and in groups under-represented in trials — chronic kidney disease, liver dysfunction, cancer, obesity, frailty, previous bleeding and valvular disease. It also addresses drug selection, interactions, bleeding management, adherence and cost.
The abstract gives no new effect sizes; this is a synthesis to complement guidelines. For clinical pharmacologists, it is a reminder that the commonest DOAC error is not the wrong drug but the wrong dose — usually an unjustified reduced dose — and that dose criteria are drug-specific.
- Check each DOAC's own dose-reduction criteria; they differ between apixaban, rivaroxaban, dabigatran and edoxaban.
- Do not reduce the dose for age or frailty alone unless the drug's criteria are met.
- Recalculate creatinine clearance with the Cockcroft–Gault equation and actual body weight at each review.
- Review interacting drugs — strong CYP3A4 and P-glycoprotein inhibitors and inducers — at every prescription change.
- Address cost directly; in India, generic apixaban and rivaroxaban have made DOACs more affordable.
Why it matters
Under-dosing silently removes stroke protection from patients who are already at the highest risk.
Don't overread it
This is a scientific statement synthesising evidence, not a new guideline or trial result.
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