title: Direct oral anticoagulant use in nonvalvular atrial fibrillation with valvular heart disease: a systematic review.
abstract: Direct oral anticoagulants (DOACs) are indicated for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF), which, according to the American College of Cardiology/American Heart Association/Heart Rhythm Society atrial fibrillation (AF) guidelines, excludes patients with rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair. However, the data regarding use of DOACs in AF patients with other types of valvular heart disease (VHD) are unclear. We aimed to summarize and evaluate the literature regarding the safety and efficacy of DOAC use in NVAF patients with other types of VHD. After an extensive literature search, a total of 1 prospective controlled trial, 4 subanalyses, and 1 abstract were identified. Efficacy of the DOAC agents in NVAF patients with VHD mirrored the overall trial results. Bleeding risk was significantly increased in VHD patients treated with rivaroxaban, but not for dabigatran or apixaban. Of the bioprosthetic valve patients enrolled in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial, no safety or efficacy concerns were identified. In conclusion, subanalyses of DOAC landmark AF trials revealed that dabigatran, rivaroxaban, and apixaban may be safely used in AF patients with certain types of VHD: aortic stenosis, aortic regurgitation, and mitral regurgitation. More evidence is needed before routinely recommending these agents for patients with bioprosthetic valves or mild mitral stenosis. Patients with moderate to severe mitral stenosis or mechanical valves should continue to receive warfarin, as these patients were excluded from all landmark AF trials.
authors.affiliation: Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma.
authors.forename: Ryan E
authors.identifier: http://orcid.org/0000-0002-6643-419X
authors.initials: RE
authors.lastname: Owens
authors.affiliation: Division of Cardiology, Department of Internal Medicine, University of Tennessee Health Science Center, Methodist University Hospital, Memphis, Tennessee.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Kabra
authors.affiliation: Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Methodist University Hospital, Memphis, Tennessee.
authors.forename: Carrie S
authors.initials: CS
authors.lastname: Oliphant
mesh_terms: D000284:Administration, Oral; D000925:Anticoagulants / Q000008:administration & dosage*; D001281:Atrial Fibrillation / Q000150:complications* / Q000188:drug therapy; D006349:Heart Valve Diseases / Q000150:complications* / Q000188:drug therapy; D006801:Humans; D012307:Risk Factors; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants
keywords: Arrhythmia/all; Clinical trials; Stroke prevention; Valvular heart disease; management