title: Impact of valvular heart disease on oral anticoagulant therapy in non-valvular atrial fibrillation: results from the RAMSES study.
abstract: The definition of non-valvular atrial fibrillation (NVAF) is controversial. We aimed to assess the impact of valvular heart disease on stroke prevention strategies in NVAF patients. The RAMSES study was a multicenter and cross-sectional study conducted on NVAF patients (ClinicalTrials.gov identifier NCT02344901). The study population was divided into patients with significant valvular disease (SVD) and non-significant valvular disease (NSVD), whether they had at least one moderate valvular disease or not. Patients with a mechanical prosthetic valve and mitral stenosis were excluded. Baseline characteristics and oral anticoagulant (OAC) therapies were compared. In 5987 patients with NVAF, there were 3929 (66%) NSVD and 2058 (34%) SVD patients. The predominant valvular disease was mitral regurgitation (58.1%), followed by aortic regurgitation (24.1%) and aortic stenosis (17.8%). Patients with SVD had higher CHA2DS2VASc [3.0 (2.0; 4.0) vs. 4.0 (2.0; 5.0), p < 0.001] and HAS-BLED [2.0 (1.0; 2.0) vs. 2.0 (1.0; 2.0), p = 0.004] scores compared to patients with NSVD. Overall, 2763 (71.2%) of NSVD and 1515 (73.8%) of SVD patients were on OAC therapy (p = 0.035). When the patients with SVD were analyzed separately, the mean CHA2DS2VASc and HAS-BLED scores were higher in patients with mitral regurgitation compared to patients with aortic regurgitation and aortic stenosis [4.0 (3.0; 5.0), 3.0 (2.0; 4.0), 3.0 (2.0; 4.0) p < 0.001 and 2.0 (1.0; 3.0), 1.0 (1.0; 2.0), 1.0 (0.0; 2.0) p < 0.001, respectively]. In patients with SVD, 65.7% of mitral regurgitation, 82.6% of aortic regurgitation and 88.0% of aortic stenosis patients were on OAC therapy. One out of three NVAF patients had at least one moderate valvular heart disease with the predominance of mitral regurgitation. Patients with SVD were at greater risk of stroke and bleeding compared to patients with NSVD. Although patients with mitral regurgitation should be given more aggressive anticoagulant therapy due to their higher risk of stroke, they are undertreated compared to patients with aortic valve diseases.
authors.affiliation: Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman Universitesi Tip Fakultesi, Orhaniye Mah. Haluk Özsoy Cad., 48000, Muğla, Turkey.
authors.forename: Özcan
authors.identifier: http://orcid.org/0000-0002-6384-6455
authors.initials: Ö
authors.lastname: Başaran
authors.affiliation: Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman Universitesi Tip Fakultesi, Orhaniye Mah. Haluk Özsoy Cad., 48000, Muğla, Turkey.
authors.forename: Volkan
authors.initials: V
authors.lastname: Dogan
authors.affiliation: Department of Cardiology, Faculty of Medicine, Sivas Cumhuriyet University, Sivas, Turkey.
authors.forename: Osman
authors.initials: O
authors.lastname: Beton
authors.affiliation: Department of Cardiology, Kahramanmaraş Necip Fazıl State Hospital, Kahramanmaraş, Turkey.
authors.forename: Mehmet
authors.initials: M
authors.lastname: Tekinalp
authors.affiliation: Department of Cardiology, Trabzon Ahi Evren Chest Cardiovascular Surgery Education and Research Hospital, Trabzon, Turkey.
authors.forename: Ahmet Çağrı
authors.initials: AÇ
authors.lastname: Aykan
authors.affiliation: Department of Cardiology, Trabzon Ahi Evren Chest Cardiovascular Surgery Education and Research Hospital, Trabzon, Turkey.
authors.forename: Ezgi
authors.initials: E
authors.lastname: Kalaycıoğlu
authors.affiliation: Department of Cardiology, Fethiye State Hospital, Muğla, Turkey.
authors.forename: Ismail
authors.initials: I
authors.lastname: Bolat
authors.affiliation: Department of Cardiology, Elazığ Education and Research Hospital, Elazig, Turkey.
authors.forename: Onur
authors.initials: O
authors.lastname: Taşar
authors.affiliation: Department of Cardiology, Burdur State Hospital, Burdur, Turkey.
authors.forename: Özgen
authors.initials: Ö
authors.lastname: Şafak
authors.affiliation: Department of Cardiology, İskilip Atıf Hoca State Hospital, Iskilip, Turkey.
authors.forename: Macit
authors.initials: M
authors.lastname: Kalçık
authors.affiliation: Department of Cardiology, Samsun Education and Research Hospital, Samsun, Turkey.
authors.forename: Mehmet
authors.initials: M
authors.lastname: Yaman
authors.affiliation: Department of Cardiology, Aksaray State Hospital, Aksaray, Turkey.
authors.forename: Sinan
authors.initials: S
authors.lastname: İnci
authors.affiliation: Department of Cardiology, Diyarbakır Gazi Yaşargil Education and Research Hospital, Diyarbakir, Turkey.
authors.forename: Bernas
authors.initials: B
authors.lastname: Altıntaş
authors.affiliation: Department of Cardiology, Gönen State Hospital, Gönen, Turkey.
authors.forename: Sedat
authors.initials: S
authors.lastname: Kalkan
authors.affiliation: Kartal Kosuyolu Heart Education and Research Hospital, Istanbul, Turkey.
authors.forename: Cevat
authors.initials: C
authors.lastname: Kırma
authors.affiliation: Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman Universitesi Tip Fakultesi, Orhaniye Mah. Haluk Özsoy Cad., 48000, Muğla, Turkey.
authors.forename: Murat
authors.initials: M
authors.lastname: Biteker
mesh_terms: D000284:Administration, Oral; D000925:Anticoagulants / Q000008:administration & dosage / Q000627:therapeutic use*; D001022:Aortic Valve Insufficiency / Q000188:drug therapy; D001281:Atrial Fibrillation / Q000188:drug therapy*; D003430:Cross-Sectional Studies; D005260:Female; D006349:Heart Valve Diseases / Q000188:drug therapy*; D006470:Hemorrhage; D006801:Humans; D008297:Male; D008875:Middle Aged; D008944:Mitral Valve Insufficiency / Q000188:drug therapy; D010818:Practice Patterns, Physicians' / Q000592:standards*; D020521:Stroke / Q000517:prevention & control
chemical_list: D000925:Anticoagulants
keywords: Atrial fibrillation; Non-valvular atrial fibrillation; Oral anticoagulant therapy; Valvular heart disease