GPAtlas🧭 When to consider
Oral anticoagulation prevents thromboembolism in patients with non-valvular atrial fibrillation, venous thromboembolism (VTE), or a mechanical heart valve. Two classes are used in UK primary care: the vitamin K antagonist warfarin, and the direct oral anticoagulants (DOACs) – apixaban, rivaroxaban, dabigatran and edoxaban.
Most prescribing decisions are made or overseen in secondary care or anticoagulation clinics. The day-to-day primary care role is safe ongoing therapy – supporting adherence, arranging monitoring, recognising and managing bleeding, navigating drug interactions, and planning around procedures. The two core skills are simple to state: keep the patient therapeutic without bleeding, and never miss a major bleed or a treatment failure.
| Indication | Agent of choice | Key point |
|---|---|---|
| Non-valvular AF (raised CHA₂DS₂-VASc) | DOAC first-line | Warfarin only if a DOAC is unsuitable. |
| VTE (DVT / PE) treatment | Apixaban or rivaroxaban | Duration set by provoked vs unprovoked status. |
| Mechanical heart valve | Warfarin only | DOACs are contraindicated. |
| Moderate-to-severe mitral stenosis / rheumatic AF | Warfarin | DOACs not recommended. |
| Antiphospholipid syndrome (triple-positive) | Warfarin | Avoid DOACs – higher thrombotic event rates. |
Source: NICE NG196 · NICE NG158
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