Choosing the optimal oral anticoagulant for stroke prevention in atrial fibrillation: direct oral anticoagulants vs vitamin K antagonists

Direct oral anticoagulants (DOACs) have replaced vitamin K antagonists (VKAs) for stroke prevention in many patients with atrial fibrillation, but VKAs may still be preferred in some situations. We use a case-based approach to present the evidence for the possible use of a VKA in preference to a DOAC in patients with atrial fibrillation and rheumatic mitral stenosis, high body mass index, frailty, and breakthrough stroke despite being prescribed a DOAC.