title: How to define valvular atrial fibrillation?
abstract: Atrial fibrillation (AF) confers a substantial risk of stroke. Recent trials comparing vitamin K antagonists (VKAs) with non-vitamin K antagonist oral anticoagulants (NOACs) in AF were performed among patients with so-called "non-valvular" AF. The distinction between "valvular" and "non-valvular" AF remains a matter of debate. Currently, "valvular AF" refers to patients with mitral stenosis or artificial heart valves (and valve repair in North American guidelines only), and should be treated with VKAs. Valvular heart diseases, such as mitral regurgitation, aortic stenosis (AS) and aortic insufficiency, do not result in conditions of low flow in the left atrium, and do not apparently increase the risk of thromboembolism brought by AF. Post-hoc analyses suggest that these conditions probably do not make the thromboembolic risk less responsive to NOACs compared with most forms of "non-valvular" AF. The pathogenesis of thrombosis is probably different for blood coming into contact with a mechanical prosthetic valve compared with what occurs in most other forms of AF. This may explain the results of the only trial performed with a NOAC in patients with a mechanical prosthetic valve (only a few of whom had AF), where warfarin was more effective and safer than dabigatran. By contrast, AF in the presence of a bioprosthetic heart valve or after valve repair appears to have a risk of thromboembolism that is not markedly different from other forms of "non-valvular" AF. Obviously, we should no longer consider the classification of AF as "valvular" (or not) for the purpose of defining the aetiology of the arrhythmia, but for the determination of a different risk of thromboembolic events and the need for a specific antithrombotic strategy. As long as there is no better new term or widely accepted definition, "valvular AF" refers to patients with mitral stenosis or artificial heart valves. Patients with "non-valvular AF" may have other types of valvular heart disease. One should emphasize that "non-valvular AF" does not exclude patients with some types of valvular heart disease from therapy with NOACs.
authors.affiliation: Service de cardiologie, faculté de médecine, université François-Rabelais, CHU Trousseau, Tours, France. Electronic address: lfau@med.univ-tours.fr.
authors.forename: Laurent
authors.initials: L
authors.lastname: Fauchier
authors.affiliation: Service de cardiologie, faculté de médecine, université François-Rabelais, CHU Trousseau, Tours, France.
authors.forename: Raphael
authors.initials: R
authors.lastname: Philippart
authors.affiliation: Service de cardiologie, faculté de médecine, université François-Rabelais, CHU Trousseau, Tours, France.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Clementy
authors.affiliation: Service de cardiologie, faculté de médecine, université François-Rabelais, CHU Trousseau, Tours, France.
authors.forename: Thierry
authors.initials: T
authors.lastname: Bourguignon
authors.affiliation: Service de cardiologie, faculté de médecine, université François-Rabelais, CHU Trousseau, Tours, France.
authors.forename: Denis
authors.initials: D
authors.lastname: Angoulvant
authors.affiliation: Service de cardiologie, faculté de médecine, université François-Rabelais, CHU Trousseau, Tours, France.
authors.forename: Fabrice
authors.initials: F
authors.lastname: Ivanes
authors.affiliation: Service de cardiologie, faculté de médecine, université François-Rabelais, CHU Trousseau, Tours, France.
authors.forename: Dominique
authors.initials: D
authors.lastname: Babuty
authors.affiliation: Service de cardiologie, faculté de médecine, université François-Rabelais, CHU Trousseau, Tours, France.
authors.forename: Anne
authors.initials: A
authors.lastname: Bernard
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000145:classification* / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D001705:Bioprosthesis; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006349:Heart Valve Diseases / Q000150:complications* / Q000175:diagnosis / Q000601:surgery; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation; D006801:Humans; D017410:Practice Guidelines as Topic; D011474:Prosthesis Design; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000209:etiology* / Q000517:prevention & control; D009626:Terminology as Topic; D013923:Thromboembolism / Q000175:diagnosis / Q000209:etiology* / Q000517:prevention & control; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D005343:Fibrinolytic Agents
keywords: Accident vasculaire cérébral; Atrial fibrillation; Fibrillation atriale; Stroke; Valve disease; Valvulopathie