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Current recommendations for anticoagulant therapy in patients with valvular heart disease and atrial fibrillation: the ACC/AHA and ESC/EACTS Guidelines in Harmony…but not Lockstep!
  1. John Preston Erwin III1,2,
  2. Bernard Iung3
  1. 1Department of Internal Medicine, Baylor Scott and White Central Texas, Temple, Texas, USA
  2. 2Texas A&M University College of Medicine, Temple, Texas, USA
  3. 3Department of Cardiology, Bichat Hospital, Paris, France
  1. Correspondence to Dr John Preston Erwin III, Department of Internal Medicine/Division of Cardiology, Scott and White Medical Center Temple, Temple, TX 76508, USA; John.ErwinIII{at}bswhealth.org

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The term non-valvular atrial fibrillation (NVAF) has become popular with the development of non-vitamin K antagonists (VKA) novel oral anticoagulants (NOAC), or direct oral anticoagulants (DOAC). Randomised trials evaluating NOACs in atrial fibrillation (AF) targeted NVAF since thromboembolic risk was presumed to be higher, and possibly to involve different mechanisms, in patients with valvular heart disease (VHD). However, it is acknowledged that the definition of NVAF is not uniform. Exclusion criteria for valvular AF differed between trials on NOACs with regard to the type and severity of native VHD and the type of valve prostheses (table 1).1–7 The availability of subgroup analyses now allows for a better risk assessment and ascertainment of indications of NOACs in patients with VHD.1 4 6 7

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Table 1

Identifying patients with ‘Nonvalvular AF’

With increasing life expectancy, the epidemic of VHD is becoming more prevalent. Simultaneously, transcatheter aortic valve implantation (TAVI) has emerged as an alternative therapy for patients with significant VHD and the ideal antithrombotic regimen for these patients has not yet been firmly established.

We review here the issues of anticoagulation in VHD, focusing on patients with AF, in the light of recent 2017 American Heart Association (AHA)/American College of Cardiology (ACC) and European Society of Cardiology (ESC)/European Association of Cardio-Thoracic Surgery (EACTS) guidelines on VHD (table 2).8 9

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Table 2

Management of atrial fibrillation in patients with valvular heart disease.

Aortic valve diseases

Anticoagulation is mainly required in aortic valve diseases in the presence of AF and conventional treatment uses VKA. In AHA/ACC guidelines, anticoagulation is indicated in patients with a CHA2DS2-VASc score ≥2 while no score threshold is mentioned in ESC/EACTS guidelines.8 9

Following subgroup analyses from randomised trials on NOACs,10 their use for the prevention of AF is now a IIa recommendation in AHA/ACC and …

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