# Oral Anticoagulants in Chronic Thromboembolic Pulmonary Hypertension: Tradition or Innovation?

## TL;DR

This paper reviews the use of direct oral anticoagulants versus vitamin K antagonists in treating chronic thromboembolic pulmonary hypertension.

## Contribution

It critically summarizes current evidence on the efficacy and safety of DOACs compared to VKAs in CTEPH patients.

## Key findings

- DOACs may be a valid alternative to warfarin for CTEPH patients.
- Evidence is limited to small studies and registries.
- Clinicians face challenges in choosing or switching anticoagulants for CTEPH.

## Abstract

Chronic thromboembolic pulmonary hypertension (CTEPH) can complicate the clinical course of patients with acute pulmonary embolism, with a variable prevalence of 0.5–4%. Beyond specific therapeutic strategies, including pulmonary endarterectomy, balloon pulmonary angioplasty and pulmonary vasodilators, lifelong anticoagulation still represents the mainstay of treatment for this condition. The main historical experience supports the use of vitamin K antagonists (VKAs) in CTEPH patients; conversely, the efficacy and safety of direct oral anticoagulants (DOACs) in this setting are unclear. Growing experience, mainly from small studies and registries, is improving our knowledge, showing that DOACs may represent a valid and promising alternative to warfarin in CTEPH patients. Therefore, in the management of cases with a newly diagnosed CTEPH, clinicians are very often in the difficult position of (a) having to choose which anticoagulant to initiate in anticoagulant-naïve patients or (b) having to evaluate whether it is necessary to switch to a VKA in patients already on DOACs. This article aims to critically summarize the current evidence comparing DOACs and VKAs in CTEPH, discussing their efficacy and safety profiles and exploring their clinical applicability.