Non-vitamin K antagonist oral anticoagulants in patients with valvular heart disease

Author:

Fanaroff Alexander C1,Vora Amit N23,Lopes Renato D34

Affiliation:

1. Division of Cardiovascular Medicine, Department of Medicine; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center; and Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA

2. UPMC Heart and Vascular Institute, Harrisburg, PA, USA

3. Division of Cardiovascular Medicine, Department of Medicine, Duke University, 2400 Pratt St, Durham, NC 27710, USA

4. Duke Clinical Research Institute, Duke University, PO Box 17969, Durham, NC 27715, USA

Abstract

Abstract The non-vitamin K antagonist oral anticoagulants (NOACs) dabigatran, rivaroxaban, apixaban, and edoxaban have transformed the management of atrial fibrillation (AF), but are only approved by regulatory authorities for stroke prophylaxis in patients with so-called “non-valvular AF.” This terminology has spawned confusion about which patients with valvular heart disease benefit from NOACs and which should be treated with vitamin K antagonists (VKAs) instead. Patients with valvular heart disease other than mechanical prosthetic valves or severe mitral stenosis (including those with bioprosthetic valves) were included in pivotal trials demonstrating the benefit of NOACs over VKAs, and consensus guidelines recommend NOACs over VKAs in these patients. Subsequent devoted randomized controlled trials in patients with AF and bioprosthetic valves, including transcatheter valves, have confirmed the safety of NOACs in this population. In patients with rheumatic mitral stenosis, observational studies indicate that NOACs may be safe and effective, but randomized controlled trials are ongoing. By contrast, a randomized controlled trial showed that dabigatran is harmful in patients with mechanical prosthetic mitral valves; however, these data may not extrapolate to patients with mechanical valve prostheses in other locations or to other NOACs, and randomized controlled trials are ongoing. In this review, we discuss these data in greater depth, and make recommendations for the use of NOACs in patients with valvular heart disease.

Funder

American Heart Association and National Institutes of Health

Bristol-Myers Squibb

Pfizer

GlaxoSmithKline

Medtronic PLC

Sanofi

Publisher

Oxford University Press (OUP)

Subject

Cardiology and Cardiovascular Medicine

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