Anticoagulation in Atrial Fibrillation and Valvular Disease

Study Questions:

Do the various types of valvular heart disease portend different outcomes in patients with atrial fibrillation (AF) undergoing treatment with oral anticoagulation (OAC)?

Methods:

This was a retrospective analysis of the ROCKET AF (n = 14,119) study, in which patients with nonvalvular AF (i.e., those without mitral stenosis or prosthetic heart valves) were randomized to warfarin or rivaroxaban. There were 1,726 patients with aortic (AR) or mitral regurgitation (MR), 214 with aortic stenosis (AS), and 12,179 with no significant valvular disease (SVD).

Results:

Patients with AS (mean age, 78 years) were older than those with AR/MR (74 years) and those without SVD (72 years). CHADS2 and HAS-BLED scores were higher in the former as well. In addition, vascular disease, obstructive lung disease, and other comorbidities were more prevalent in patients with AS. Thromboembolism and all-cause mortality were higher in patients with AS than in the other groups; there was no difference between the AR/MR and those without SVD. Major bleeding was also more common in the AS group. The relative efficacy of rivaroxaban with respect to warfarin was not different in those with and without valvular disease.

Conclusions:

The authors concluded that patients with AS and AF may have worse outcomes while taking OAC, as compared to those with regurgitant lesion or those without valvular disease.

Perspective:

The AS patients were significantly older and had more comorbidities, which may help explain their worse outcomes. From a methodological standpoint, the severity of the valvular disease was not specified in the parent study, and the echocardiographic data were not analyzed in a core laboratory. In the absence of randomized data, it is difficult to accept the findings of this study as definitive.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease, Mitral Regurgitation

Keywords: Anticoagulants, Aortic Valve Insufficiency, Aortic Valve Stenosis, Arrhythmias, Cardiac, Atrial Fibrillation, Cardiac Surgical Procedures, Geriatrics, Heart Valve Diseases, Hemorrhage, Lung Diseases, Obstructive, Mitral Valve Insufficiency, Thromboembolism, Warfarin


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