Direct Oral Anticoagulants: A Delicate and Dynamic Balance.

I read with interest the article by Raccah et al, focusing on the impact of prescribing errors with direct oral anticoagulants (DOACs) on the risk of bleeding in patients with atrial fibrillation (AF). The prevalence of errors, consisting in either unjustified low dosage or inappropriate drugs combinations, with a consequent higher major bleeding risk, appears significantly high (33%), but not surprising, since adhering to clinical reality, as we similarly observe in our routine practice. We totally agree with the authors, who remark the importance of being aware of the potential negative impact of prescribing errors and regular follow-up. Moreover, a recent retrospective analysis conducted by Chaudhry et al, focusing on outcome of patients 80 years receiving low dose DOACs, evidenced in the low dose group a higher all-cause mortality rate, as long as higher rate of major bleeding, while the thromboembolic events were not significantly lower than the warfarin group. These results represent a mirror of clinical practice also in our daily experience. About these observations, I would like to stress some trends we commonly encounter with patients affected by AF taking DOACs, which we believe many of our colleagues will share: