Abstract
Atrial fibrillation (AF) is a major worldwide public health problem, and AF in association with valvular heart disease (VHD) is also common. However, management strategies for this group of patients have been less informed by randomized trials, which have largely focused on 'non-valvular AF' patients. Thrombo-embolic risk also varies according to valve lesion and may also be associated with CHA2DS2VASc score risk factor components, rather than only the valve disease being causal. Given marked heterogeneity in the definition of valvular and non-valvular AF and variable management strategies, including non-vitamin K antagonist oral anticoagulants (NOACs) in patients with VHD other than prosthetic heart valves or haemodynamically significant mitral valve disease, there is a need to provide expert recommendations for professionals participating in the care of patients presenting with AF and associated VHD. To address this topic, a Task Force was convened by the European Heart Rhythm Association (EHRA) and European Society of Cardiology (ESC) Working Group on Thrombosis, with representation from the ESC Working Group on Valvular Heart Disease, Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), South African Heart (SA Heart) Association and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE) with the remit to comprehensively review the published evidence, and to publish a joint consensus document on the management of patients with AF and associated VHD, with up-to-date consensus recommendations for clinical practice for different forms of VHD. This consensus document proposes that the term 'valvular AF' is outdated and given that any definition ultimately relates to the evaluated practical use of oral anticoagulation (OAC) type, we propose a functional Evaluated Heartvalves, Rheumatic or Artificial (EHRA) categorization in relation to the type of OAC use in patients with AF, as follows: (i) EHRA Type 1 VHD, which refers to AF patients with 'VHD needing therapy with a Vitamin K antagonist (VKA); and (ii) EHRA Type 2 VHD, which refers to AF patients with 'VHD needing therapy with a VKA or a Non-VKA oral anticoagulant (NOAC)', also taking into consideration CHA2DS2VASc score risk factor components. This consensus document also summarizes current developments in the field, and provides general recommendations for the management of these patients based on the principles of evidence-based medicine.
Highlights
An appropriate definition of ‘valvular Atrial fibrillation (AF)’ would need to identify a subgroup of patients with similar pathophysiology of thrombo-embolism, TE risk, and treatment strategies[6,9]; this would be challenging given the major heterogeneity of the condition. This consensus document proposes that the term ‘valvular AF’ is outdated and given that any definition relates to the evaluated practical use of oral anticoagulation (OAC) type, we propose a functional EHRA (Evaluated Heartvalves, Rheumatic or Artificial) categorization in relation to the type of OAC use in patients with AF, as follows: Evaluated Heartvalves, Rheumatic or Artificial (EHRA) Type 1, which refers to AF patients with ‘valvular heart disease (VHD) needing therapy with a Vitamin K antagonist (VKA)’
In the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) AF Registry which enrolled patients presenting to an emergency department with AF at 164 sites in 46 countries, rheumatic heart disease was present in 2.2% of North American patients, in comparison with 21.5% in Africa and 31.5% in India[7]; interestingly thrombo-embolism rates were related to clinical risk profile, as expressed by CHADS2 score, irrespective of the presence of rheumatic VHD
Non-vitamin K antagonist oral anticoagulants can be prescribed to some subgroups of patients with VHD6,127,128 and a series of analyses focusing on the cost-effectiveness of these agents vs. warfarin has been published, no study considered separately patients with VHD
Summary
Veterans General Hospital, and Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (APHRS reviewer); 25University of Rome La Sapienza, Rome, Italy; 26Department of Cardiology, Max Super Specialty Hospital, New Delhi, India; 27Hospital de ClUnicas de Porto Alegre, Federal University of Rio Grande do Sul, Brasil (SOLAECE reviewer); 28Duke University Medical Center, Duke Clinical Research Institute, Durham, USA (HRS reviewer); 29Department of Cardiovascular Sciences, University of Sheffield, Sheffield, UK; 31Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway; 30National Heart and Lung Institute, Imperial College, London, and Postgraduate Medicine, University of Hertfordshire, Hertfordshire, UK; 32Ospedale Maggiore, Division of Cardiology, Bologna, Italy (Working Group of Thrombosis reviewer); 33Electrophysiology and Pacing, Groote Schuur Hospital, University of Cape Town, South Africa (CASSA reviewer); and 34Department of Medicine, Division of Cardiology, University of Cape Town, South Africa (SAHeart reviewer).
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