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Direct Oral Anticoagulants for Mitral Stenosis
Study Questions:
What is the efficacy of direct oral anticoagulants (DOACs) in patients with mitral stenosis?
Methods:
The authors used the Health Insurance Review and Assessment Service database from Korea to identify patients with mitral stenosis and atrial fibrillation who were prescribed DOAC therapy or warfarin. They used 1:1 propensity-score matching to create similar DOAC- and warfarin-treated cohorts. The primary efficacy endpoint was ischemic stroke or systemic embolism. The primary safety endpoint was intracranial hemorrhage.
Results:
A total of 2,230 patients (mean age 69.7 ± 10.5 years, 30.6% male) were included in the analysis. Thrombotic events occurred in 2.22%/year in the DOAC group as compared to 4.19%/year in the warfarin group (adjusted hazard ratio [aHR], 0.28; 95% confidence interval [CI], 0.18-0.45). Intracranial hemorrhage occurred in 0.49% of the DOAC-treated patients versus 0.93% of the warfarin-treated patients (aHR, 0.53; 95% CI, 0.22-1.26).
Conclusions:
The authors concluded that DOAC use in patients with mitral stenosis and atrial fibrillation is a promising therapy that requires future validation in a prospective randomized trial.
Perspective:
Current recommendations for DOAC use are limited to patients with “nonvalvular” atrial fibrillation. This excludes patients with mechanical valve replacement or moderate/severe mitral stenosis from receiving DOAC therapy. While this study of Korean patients with atrial fibrillation and mitral stenosis suggests that DOAC therapy may be safe, there were no data on the severity of mitral stenosis in the study population. Despite prior randomized trial data showing increased thromboembolic events with DOAC therapy in the mechanical valve replacement population, it stands to reason that DOAC therapy could be safe and effective in mitral stenosis patients without valve replacement. However, as the authors suggest, prospective data (preferably randomized) would be needed before DOAC therapy for mitral stenosis patients with atrial fibrillation should be considered standard of care.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Prevention, Valvular Heart Disease, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Anticoagulants, Atrial Fibrillation, Brain Ischemia, Embolism, Heart Valve Diseases, Intracranial Hemorrhages, Mitral Valve Stenosis, Primary Prevention, Stroke, Thromboembolism, Vascular Diseases, Warfarin
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