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. 2020 Dec 14;6(13):1672-1682.
doi: 10.1016/j.jacep.2020.07.005. Epub 2020 Aug 28.

Thromboembolic Risk in Nonanticoagulated Patients With Atrial Fibrillation and Valvular Heart Disease

Line Melgaard  1 , Thure Filskov Overvad  2 , Martin Jensen  3 , Gregory Y H Lip  4 , Torben Bjerregaard Larsen  2 , Peter Brønnum Nielsen  2
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Free article

Thromboembolic Risk in Nonanticoagulated Patients With Atrial Fibrillation and Valvular Heart Disease

Line Melgaard et al. JACC Clin Electrophysiol. .
Free article

Abstract

Objectives: This study sought to describe the risk of thromboembolism in nonanticoagulated atrial fibrillation patients with Evaluated Heartvalves, Rheumatic or Artificial (EHRA) Type 2 valvular heart disease (VHD) <65 or 65 to 74 years of age and with 0 or 1 non-sex comorbidity of the CHA2DS2-VASc score.

Background: A minor, but important, proportion of patients with atrial fibrillation and VHD beyond moderate-to-severe mitral stenosis and/or a mechanical prosthetic valve, so-called EHRA Type 2 VHD, have 0 or 1 coexisting non-sex comorbidities of the CHA2DS2-VASc score, and are therefore not strongly recommended oral anticoagulant therapy according to guidelines. Whether these patients are truly low risk of thromboembolism has not been investigated.

Methods: This was a cohort study of 55,613 patients identified in nationwide Danish registries from 2000 to 2018, of which 1,907 patients had EHRA Type 2 VHD. Risk of thromboembolism after 1 and 5 years of follow-up were calculated.

Results: At 1 year after atrial fibrillation diagnosis, patients with EHRA Type 2 VHD had a risk of thromboembolism between 1.2% and 1.5%, according to age group (<65 or 65 to 74 years of age), and number of non-sex comorbidities of the CHA2DS2-VASc score (0 or 1). Interestingly, in patients with EHRA Type 2 VHD <65 years of age with 0 or 1 comorbidity, the risk was 1.5% (95% confidence interval: 0.7% to 2.8%) and 1.5% (95% confidence interval: 0.6% to 3.4%) at 1 year after the atrial fibrillation diagnosis.

Conclusions: These observations suggest that in atrial fibrillation patients with EHRA Type 2 VHD, who are not currently recommended oral anticoagulant therapy according to guidelines, the risk of thromboembolism may exceed the level above which oral anticoagulation is considered beneficial.

Keywords: CHA(2)DS(2)-VASc score; atrial fibrillation; risk; thromboembolism; valvular heart disease.

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Conflict of interest statement

Author Disclosures The study was supported by “The BMS/Pfizer European Thrombosis Investigator Initiated Research Program (ERISTA) 2018” and the Obel Family Foundation. Dr. Melgaard has received grant support from Bristol-Myers Squibb/Pfizer. Prof. Lip has been a consultant for Bayer/Janssen, Bristol-Myers Squibb/Pfizer, Biotronik, Medtronic, Boehringer Ingelheim, Microlife, and Daiichi Sankyo; and has been a speaker for Bayer, Bristol-Myers Squibb/Pfizer, Medtronic, Boehringer Ingelheim, Microlife, Roche, and Daiichi Sankyo. No fees were received personally. Prof. Larsen has been an investigator for Janssen Scientific Affairs, LLC, and Boehringer Ingelheim; and has been a speaker for Bayer, Bristol-Myers Squibb/Pfizer, Janssen Pharmaceuticals, Takeda, Roche Diagnostics, and Boehringer Ingelheim. No fees were received personally. Dr. Nielsen has received speaking fees from Boehringer Ingelheim; has received consulting fees from Bayer; and has received grant support from Bristol-Myers Squibb/Pfizer. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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