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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
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
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 …
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
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