Preserving Expertise in Vitamin K Antagonists in the Era of Direct Oral Anticoagulants: Avoiding Therapeutic Segregation.

The rapid uptake of direct oral anticoagulants (DOACs) has sharply reduced the prescribing of vitamin K antagonists (VKAs), giving rise to an underappreciated risk: the progressive loss of the clinical expertise required to manage them. Yet several populations remain dependent on VKAs, including patients with mechanical heart valves, high-risk antiphospholipid syndrome, and advanced renal disease, as well as patients in resource-limited settings. These patients face both the intrinsic complexity of VKA therapy and a healthcare environment in which practical experience with these agents is becoming scarce. Preserving this competence is a matter of patient safety and professional responsibility. We argue for a structured response combining education, the maintenance of specialized anticoagulation clinics, patient empowerment, and anticoagulation stewardship, with artificial intelligence remaining, for now, only a prospect.