Preserving expertise in vitamin K antagonists in the era of direct oral anticoagulants: avoiding therapeutic segregation.

The rapid uptake of direct oral anticoagulants 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 health care 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.