Anticoagulation Myth Busters

MYTH

“Patients with any form of valve disease are not suitable for NOACs”

REALITY

“Valvular heart disease can be associated with an increased thromboembolic risk, and historically patients with AF have been categorised as either “valvular” or “non-valvular”. In the context of AF, “non-valvular” refers to AF in the absence of a mechanical prosthetic heart valve or moderate to severe mitral stenosis (usually of rheumatic origin).1

NOACs are licensed for use in patients with non-valvular AF.”2-5

Patients with moderate/severe mitral stenosis or those with mechanical prosthetic heart valves (conditions known to be associated with particularly high thromboembolic risk) were consistently excluded from the main NOAC randomised controlled trials. The pathogensis of thrombus formation in these patient groups is markedly different to that seen in patients with non-valvular AF, and as such oral anticoagulation with a vitamin K antagonist (VKA) e.g. warfarin is recommended.6

As shown in figure 1, in patients diagnosed with AF who undergo bioprosthetic (tissue) valve replacement or repair or in those in whom mitral regurgitation/aortic stenosis/aortic insufficiency is noted, a VKA or a NOAC can be prescribed for stroke prevention. However, in the context of moderate/severe mitral stenosis or mechanical heart valve, treatment with a VKA is recommended.6,7,8

Figure 1: Valvular heart disease and recommended OAC strategy for SPAF 1,6,7,8

REFERENCES
  1. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal. 2016;37(38):2893-962.
  2. SmPC Apixaban. medicines.org.uk: medicines.org.uk; 2019.
  3. SmPC Dabigatran. medicines.org.uk; 2019.
  4. SmPC Edoxaban. medicines.org.uk: medicines.org.uk; 2019.
  5. SmPC Rivaroxaban. medicines.org.uk: medicines.org.uk; 2019.
  6. Eikelboom JW, Connolly SJ, Brueckmann M, Granger CB, Kappetein AP, Mack MJ, et al. Dabigatran versus warfarin in patients with mechanical heart valves. N Engl J Med. 2013;369(13):1206-14.
  7. Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Desteghe L, et al. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: executive summary. Europace. 2018.
  8. De Caterina R, Camm AJ. What is ‘valvular’ atrial fibrillation? A reappraisal. European Heart Journal. 2014;35(47):3328-35.
  9. NICE CG 180. Atrial fibrillation: management. In: Excellence NIfHaC, editor. NICE: NICE; 2014.
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