Non-vitamin K oral anticoagulants in 'valvular' atrial fibrillation: a call for action.

Abstract

This editorial refers to ‘Non-vitamin K antagonist oral anticoagulants in atrial fibrillation accompanying mitral stenosis: the concept for a trial’ by R. De Caterina and A.J. Camm, doi:10.1093/europace/euv288. Non-vitamin K oral anticoagulants (NOACs) have become the standard of care for stroke prevention in patients with non-valvular atrial fibrillation (AF), based on the impressive efficacy and safety data demonstrated in four independent large-scale clinical trials.1–6 However, while the general concept and recommendations for the use of NOACs are being well conceived, the term ‘non-valvular’ has caused substantial confusion in daily clinical practice.7 First, its definition is not uniform across different guidelines. While the most recent ESC Guideline update in 2012 defines ‘valvular AF’ as rheumatic valvular disease (predominantly mitral stenosis) or prosthetic heart valves,5 current AHA/ACC/HRS Guidelines in addition explicitly include bioprosthetic valves and mitral valve repair.8 The second problem relates to the fact that the exclusion criteria due to valvular disease were not uniform across different NOAC trials. For example, the exclusion criteria in the ROCKET-AF trial were prosthetic heart valve or haemodynamically significant mitral stenosis, whereas in the ENGAGE-AF TIMI 48 trial, these were moderate or severe mitral stenosis, or a mechanical heart valve (whilst bioprosthetic heart valves and/or valve repair were allowed).2,4 As a result, uncertainty persists among practicing physicians whether a given patient with valvular heart disease is eligible for NOAC treatment. As a result, patients with valvular disorders other than the ones mentioned above, including frequently encountered entities such as aortic stenosis or mild-to-moderate mitral regurgitation, were often denied NOACs based on the perception that they were suffering from valvular AF. Indeed, this issue has …