Non-vitamin K antagonist oral anticoagulants in atrial fibrillation accompanying mitral stenosis: the concept for a trial
- 7 October 2015
- journal article
- review article
- Published by Oxford University Press (OUP) in EP Europace
- Vol. 18 (1), 6-11
- https://doi.org/10.1093/europace/euv288
Abstract
Patients at thromboembolic risk with non-valvular atrial fibrillation (AF) can now be managed either with a vitamin K antagonist (VKA) or with a fixed dose of a non-VKA oral anticoagulant (NOAC), while patients with valvular AF have been restricted to VKAs on the basis of a potentially higher risk and different mechanism of thrombosis, and the lack of sufficient data on the efficacy of NOACs. The terms ‘non-valvular AF’ and ‘valvular AF’ have not been however consistently defined. ‘Valvular’ AF has included any valvular disorder, including valve replacement and repair. In AF with rheumatic mitral disease, observational studies strongly suggest that VKA treatment is valuable. These patients have not been included in NOAC trials, but there is also no stringent argument to have excluded them. This is at sharp variance from patients with mechanical valves, also excluded from the pivotal Phase III trial comparing warfarin with NOACs, but in whom a single Phase II trial of dabigatran etexilate against VKA treatment was stopped prematurely because of increased rates of thromboembolism as well as increased bleeding associated with dabigatran. Until more data are available, such patients should be therefore managed with VKAs. We here propose an open-label randomized trial of one of the NOACs against the best of treatment available in regions of the world in which rheumatic heart disease is still highly prevalent, aiming at showing the superiority of the NOAC used against current standard treatment.This publication has 45 references indexed in Scilit:
- D-Dimer assay as a non invasive test for the diagnosis of left atrial Thrombi in Indian patients with Rheumatic MSAfrican Health Sciences, 2013
- Massive Left Atrial Thrombus in a Patient With Rheumatic Mitral Stenosis and Atrial Fibrillation While Anticoagulated With DabigatranCirculation: Cardiovascular Imaging, 2013
- Antithrombotic Therapy for Atrial Fibrillation: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice GuidelinesSocial psychiatry. Sozialpsychiatrie. Psychiatrie sociale, 2012
- Apixaban versus Warfarin in Patients with Atrial FibrillationThe New England Journal of Medicine, 2011
- Incidence and Predictors of Left Atrial Thrombus in Patients with Rheumatic Mitral Stenosis and Sinus Rhythm: A Transesophageal Echocardiographic StudyEchocardiography, 2011
- Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort studyBMJ, 2011
- Giant atrial thrombusInternal Medicine Journal, 2011
- An Appreciation of Mitral Stenosis--IIBMJ, 1954
- An Appreciation of Mitral Stenosis--IBMJ, 1954
- Systemic arterial embolism in rheumatic heart diseaseAmerican Heart Journal, 1951