DOACs in valvular atrial fibrillation 

AF worsens the prognosis of people with severe valvular disease.5 However, DOACs are generally indicated for nonvalvular AF, which denotes patients without rheumatic valvular disease (predominantly mitral stenosis) or prosthetic heart valves.5 These patients were excluded from the RCTs.46,48 Nevertheless, in most studies of DOACs about 20% of enrolled patients had valvular defects, including mild mitral stenosis, mitral regurgitation, aortic stenosis, aortic regurgitation and tricuspid regurgitation.37 DOACs are effective in people with native valvular AF, producing similar reductions in stroke, systemic embolism and intracranial haemorrhage compared with warfarin in people with and without valvular AF.46,48

DOAC in valvular heart disease

A meta-analysis of four RCTs encompassed 71,526 AF patients, including 13,574 with valvular heart disease. Compared with warfarin, DOACs reduced the risk of stroke or systemic embolism by 30% and 16% in those with and without valvular heart disease respectively. No significant difference in mortality emerged in patients with valvular heart disease, but declined by 18% in those without valvular disease. Neither group showed a significant difference in the rate of major bleeds. However, the risk of intracranial haemorrhage was 53% and 51% lower compared with warfarin in those with and without valvular disease respectively.46

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