A task force of investigators from the European Heart Rhythm Association and European Society of Cardiology Working Group on Thrombosis, Heart Rhythm Society, Asia Pacific Heart Rhythm Society, South African Heart Association, and the Sociedad Latinoamericana de Estimulacion Cardıaca y Electrofisiologıa has provided updated antithrombotic therapy recommendations for patients with atrial fibrillation (AF) associated with valvular heart disease in a recent paper published in Europace.
In this statement, the use of oral anticoagulation with vitamin K in patients with AF with mechanical heart valves was one area the task force approached. Based on current evidence, the task force suggested that oral anticoagulation and vitamin K antagonists are important for preventing thromboembolism in this patient population.
Other recommendations included the use of vitamin K antagonists plus low-dose aspirin (75 to 100 mg daily) in patients with mechanical prosthetic valves and concomitant AF. When used, the investigators recommended maintaining the international normalized ratio between 2.0 and 3.0, considering the high bleeding risk associated with this combination therapy.
The task force states that non-vitamin K antagonist oral anticoagulants are contraindicated in patients with AF with mechanical valve prostheses. Currently, apixaban, edoxaban, and rivaroxaban are contraindicated in these patients.
In patients undergoing mitral valve repair, oral anticoagulants are also recommended during the initial 3 to 6 months following surgery. In addition, patients with bioprostheses may require the use of oral anticoagulants throughout life, particularly if they present with additional embolism risk factors.
In order to optimize therapy costs, the task force also urged physicians to remember that “improved adherence to [oral anticoagulant therapy] in patients [with] atrial fibrillation at risk [for] stroke is important in order to attain the full clinical and economic benefit of thromboprophylaxis.”
Lip GYH, Collet JP, Caterina R, et al. Antithrombotic therapy in atrial fibrillation associated with valvular heart disease: a joint consensus document from the European Heart Rhythm Association (EHRA) and European Society of Cardiology Working Group on Thrombosis, endorsed by the ESC Working Group on Valvular Heart Disease, Cardiac Arrhythmia Society of Southern Africa (CASSA), 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). Europace. 2017 Nov 1;19(11):1757-1758.