Characteristics and Prognosis of Patients With Nonvalvular Atrial Fibrillation and Significant Valvular Heart Disease Referred for Electrical Cardioversion

N Mai Vo,Melissa Leung,Phillippe J Van Rosendael,Laurien Goedemans,Suzanne E Van Wijngaarden,Edgard A Prihadi,Pieter Van Der Bijl,Nina Ajmone Marsan,Victoria Delgado,Jeroen J Bax

doi:10.1016/j.amjcard.2020.04.035

N Mai Vo, Melissa Leung + Show 8 more

Open Access

https://doi.org/10.1016/j.amjcard.2020.04.035

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Abstract

Valvular atrial fibrillation (AF) is defined as AF in the presence of mitral stenosis or mechanical valve prosthesis. However, there are patients with AF who have significant native valvular heart disease (VHD) others than mitral stenosis that are classified as nonvalvular AF. The characteristics and prognostic implications of these entities have not been extensively studied. Of 1,885 AF patients referred for electrical cardioversion (64 ± 13years, 71% male), 171 (9.1%) had valvular AF (any grade of mitral stenosis or mechanical/biological valve prostheses) and 1,714 patients were identified as nonvalvular AF, of whom 329 (17.5%) had significant left-sided VHD. Patients with nonvalvular AF but with significant left-sided VHD were older, more frequently women and had more co-morbidities compared with the other groups. Furthermore, nonvalvular AF patients with significant left-sided VHD showed the worst left ventricular systolic function and largest left atrial volumes. During a median follow-up of 64 months (interquartile range: 33 to 96 months), 488 patients presented with the combined endpoint of all-cause mortality, heart failure hospitalization, and ischemic stroke. Patients with nonvalvular AF and with significant left-sided VHD had more events of heart failure whereas patients with valvular AF had higher all-cause mortality events. There were no differences in ischemic stroke events. Type of AF was not associated with outcomes after correcting for echocardiographic variables. In conclusion, the frequency of AF patients with significant VHD is relatively high. The consequences of VHD and AF on cardiac structure and function are more important determinants of adverse outcome than the type of AF.

Highlights

Consider DOACs as an alternative to vitamin K antagonists
The present study reports a relatively low prevalence of valvular atrial fibrillation (AF) but relatively high frequency of AF patients with significant valvular heart disease (VHD)
The majority of the randomized clinical trials on the efficacy of DOACs in AF patients excluded patients with valvular AF, post hoc analyses have demonstrated that a significant proportion of patients had VHD.[12−15] A metaanalysis of 4 DOAC trials[1,12−15] comparing the prevalence and outcome of 58,095 AF patients without VHD (81%) versus 13,585 (19%) with VHD showed that the most frequent VHD in patients with nonvalvular AF was moderate to severe mitral regurgitation (73.3% to 87.7%) followed by moderate to severe aortic regurgitation (13% to 24.3%) and moderate to severe aortic stenosis (5.8% to 11.9%).[1,12−15] the RE-LY trial excluded any valve intervention,[14] the ROCKET-AF study included valve repair (2.1%) and valvuloplasty (3.2%) but excluded bioprosthetic heart valves.[15]

Summary

Introduction

Consider DOACs as an alternative to vitamin K antagonists (class IIa recommendation). We investigated the clinical and echocardiographic characteristics that influence the association between type of AF (valvular vs nonvalvular) and clinical outcomes

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Conclusion