Dr Murray B. Trusler’s letter in the April 2023 issue of Canadian Family Physician1 concerned team-based care to improve time in therapeutic range with the use of warfarin. He documents how the use of ancillary personnel and new technologies can successfully ease the burden of anticoagulation monitoring in primary care. While the newer direct oral anticoagulants (DOACs) can obviate this burden, these drugs are often inaccessible to those of lower income in our increasingly inequitable society.
Dr Trusler goes on to say that DOACs have failed to reduce the incidence of stroke and systemic embolism compared with warfarin. He cites a Canadian retrospective cohort study by Durand et al2 as evidence. What is not mentioned is that the same study found an association with reduced major bleeding, intracranial hemorrhage (ICH), and all-cause mortality with DOAC use. In fact, if we consider the much higher level of evidence shown in meta-analyses of randomized controlled trials, DOACs have been associated with reductions in stroke, ICH, fatal bleeding, and all-cause mortality compared with warfarin.3,4 Only gastrointestinal bleeding was increased, while ICH, a devastating cause of death and disability, was reduced by more than 50%.5
The 2020 Canadian Cardiovascular Society guidelines recommend DOACs for anticoagulation in nonvalvular atrial fibrillation and, additionally, switching to these agents from warfarin wherever possible.6 An approach to use of these guidelines appears in the same issue of the journal.7 Those who must continue taking warfarin will, of course, greatly benefit from a team-based approach to monitoring.
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Competing interests
None declared
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