Three speeds in VKA-to-DOAC transition: Spain, Valencia and one department, 2021–2024

Background The Spanish Atlas of poor anticoagulation control reports that 48.3% of patients with non-valvular atrial fibrillation (NVAF) treated with vitamin K antagonists (VKAs) have suboptimal control, affecting about 251,000 patients and causing avoidable strokes, major bleeds, deaths and an annual burden close to €800 million. Expert societies call for indicators to detect poor control and timely switching to direct oral anticoagulants (DOACs). This study compares VKA-to-DOAC transition in Spain, the Valencian Community (VC) and one health department (Dep_05). Methods Ecological drug-utilisation study using 2021–2024 consumption data for acenocoumarol, warfarin, dabigatran, rivaroxaban, apixaban and edoxaban, expressed as DDD/1,000 inhabitants/day. For each level, VKA DDD, DOAC DDD and DOAC share [DOAC/(DOAC+VKA)] were calculated as transition indicators. Results In Spain, DOACs increased from 10.2 to 13.9 DDD/1,000/day between 2021 and 2024, while VKAs fell from 5.6 to 4.3, raising DOAC share from 64.5% to 76.2%. In the VC, DOAC share was consistently higher (66.9–78.2%), with lower VKA exposure (4.9 to 3.9) and the same 2024 DOAC level as Spain (13.9). Dep_05 showed the most advanced transition: DOACs represented 75.0% of oral anticoagulant DDD in 2023 and 79.4% in 2024, with the lowest VKA exposure (3.36 vs 3.87 in VC and 4.34 in Spain). Its mix was more DOAC-centred, with higher dabigatran, apixaban and edoxaban use and lower rivaroxaban use. Conclusions Spain is moving from VKAs to DOACs, but transition intensity differs by territory. The VC is ahead of the national pattern and Dep_05 shows an early-adopter profile, with lower residual VKA exposure at similar overall anticoagulant use. Since poor VKA control carries avoidable clinical/economic burden, residual risk is likely unevenly distributed by residence. Identifying organisational and policy factors behind faster transition could reduce territorial inequities and improve anticoagulation outcomes. Key messages • Spain shows a clear territorial gradient in VKA-to-DOAC transition, with Valencia ahead and Dep_05 showing an early-adopter profile. • Residual VKA exposure may concentrate avoidable risk by residence, supporting policies to reduce inequities in anticoagulation quality.