title: Defining nonvalvular atrial fibrillation: A quest for clarification.
abstract: Non-vitamin K oral anticoagulants (NOACs) are currently recommended for patients with nonvalvular atrial fibrillation since the publication of the 4 major pivotal trials evaluating the efficacy and safety of factor IIa and factor Xa inhibitors. The definition of nonvalvular atrial fibrillation is unclear, varying from one trial to another and even between North American and European guidelines, which is a source of uncertainties in clinical practice. However, many patients with atrial fibrillation present signs of valvular involvement, and clarification of this term is needed to not deny NOACs to patients based on the wrong perception that they may have valvular atrial fibrillation. The currently unique contraindications to NOACs are patients with mechanical heart valves and those with moderate-to-severe mitral stenosis, as stated by the recent 2015 position paper of the European Heart Rhythm Association. Patients with native heart valve involvement, regardless of their severity, are suitable for NOAC therapy. Patients with bioprosthetic heart valves and mitral valve repair may be suitable for NOACs except for the first 3 and the first 3-6 months postoperatively, respectively. Patients with transaortic valve implantation or percutaneous transluminal aortic valvuloplasty are also considered as being eligible for NOACs, although the bleeding risk has to be carefully considered in this population often requiring a combination with antiplatelet therapy. Future studies are warranted to increase the level of evidence of use of NOACs, particularly in patients with transaortic valve implantation and valvular surgery, and to determine whether they could be used in the future in the only 2 remaining contraindications.
authors: CHU Rennes, Service de Cardiologie et Maladies Vasculaires, Rennes, F-35000, France; Université de Rennes 1, CIC-IT 804, Rennes, F-35000, France; INSERM, U1099, Rennes, F-35000, France; INSERM 1414 Clinical Investigation Center, Innovative Technology, Rennes, F-35000, France. Electronic address: raphael.martins@chu-rennes.fr.
authors: Raphaël P
authors: RP
authors: Martins
authors: CHU Rennes, Service de Cardiologie et Maladies Vasculaires, Rennes, F-35000, France; Université de Rennes 1, CIC-IT 804, Rennes, F-35000, France; INSERM, U1099, Rennes, F-35000, France; INSERM 1414 Clinical Investigation Center, Innovative Technology, Rennes, F-35000, France.
authors: Vincent
authors: V
authors: Galand
authors: CHU Rennes, Service de Cardiologie et Maladies Vasculaires, Rennes, F-35000, France; Université de Rennes 1, CIC-IT 804, Rennes, F-35000, France; INSERM, U1099, Rennes, F-35000, France; INSERM 1414 Clinical Investigation Center, Innovative Technology, Rennes, F-35000, France.
authors: Edouard
authors: E
authors: Colette
authors: CHU Rennes, Service de Cardiologie et Maladies Vasculaires, Rennes, F-35000, France; Université de Rennes 1, CIC-IT 804, Rennes, F-35000, France; INSERM, U1099, Rennes, F-35000, France; INSERM 1414 Clinical Investigation Center, Innovative Technology, Rennes, F-35000, France.
authors: Nathalie
authors: N
authors: Behar
authors: CHU Rennes, Service de Cardiologie et Maladies Vasculaires, Rennes, F-35000, France; Université de Rennes 1, CIC-IT 804, Rennes, F-35000, France; INSERM, U1099, Rennes, F-35000, France; INSERM 1414 Clinical Investigation Center, Innovative Technology, Rennes, F-35000, France.
authors: Dominique
authors: D
authors: Pavin
authors: CHU Rennes, Service de Cardiologie et Maladies Vasculaires, Rennes, F-35000, France; Université de Rennes 1, CIC-IT 804, Rennes, F-35000, France; INSERM, U1099, Rennes, F-35000, France; INSERM 1414 Clinical Investigation Center, Innovative Technology, Rennes, F-35000, France.
authors: Christophe
authors: C
authors: Leclercq
authors: CHU Rennes, Service de Cardiologie et Maladies Vasculaires, Rennes, F-35000, France; Université de Rennes 1, CIC-IT 804, Rennes, F-35000, France; INSERM, U1099, Rennes, F-35000, France; INSERM 1414 Clinical Investigation Center, Innovative Technology, Rennes, F-35000, France.
authors: Jean-Claude
authors: JC
authors: Daubert
authors: CHU Rennes, Service de Cardiologie et Maladies Vasculaires, Rennes, F-35000, France; Université de Rennes 1, CIC-IT 804, Rennes, F-35000, France; INSERM, U1099, Rennes, F-35000, France; INSERM 1414 Clinical Investigation Center, Innovative Technology, Rennes, F-35000, France.
authors: Philippe
authors: P
authors: Mabo
mesh_terms: D000991:Antithrombins; D001281:Atrial Fibrillation / Q000145:classification* / Q000188:drug therapy / Q000209:etiology; D001705:Bioprosthesis; D000075202:Contraindications; D065427:Factor Xa Inhibitors; D006349:Heart Valve Diseases / Q000150:complications; D006350:Heart Valve Prosthesis; D006801:Humans; D008946:Mitral Valve Stenosis / Q000150:complications; D020521:Stroke / Q000209:etiology / Q000517:prevention & control
chemical_list: D000991:Antithrombins; D065427:Factor Xa Inhibitors