ACC/AHA Clarify When AF Patients With Mitral Stenosis Should—And Should Not—Take DOACs

December 24, 2020
Larry Hanover

The distinction between valvular and nonvalvular atrial fibrillation (AF) has been a persistent point of confusion for clinicians.

Experts from leading cardiology societies have updated atrial fibrillation performance measures to incorporate a clarification that valvular atrial fibrillation refers to patients with moderate or severe mitral stenosis or a mechanical heart valve.1

The distinction between valvular and nonvalvular atrial fibrillation (AF) has been a persistent point of confusion for clinicians, with trials for both nonvitamin K oral anticoagulants and direct-acting anticoagulants using varying definitions. Variation has also existed between North American and European guidelines. Valvular AF calls for treatment with long-term anticoagulation with warfarin.

The performance measures are taken from the 2019 American College of Cardiology/American Heart Association/Heart Rhythm Society guideline update2 addressing chronic anticoagulation therapy and were published December 7, 2020. The updates incorporate only the strongest recommendations from the 2019 task force update. The document provides quality measures that are not ready yet for public reporting or pay-for-performance programs. However, the task force provided the information to help guide clinicians and healthcare organizations with treatment of valvular AF.

“The changes were to align with the ACC/AHA guidelines that made 2 changes that impacted the performance measures,” said Paul A. Heidenrich, MD, MS, professor of Medicine at Stanford and chair of the writing committee. “One was the definition of valve disease that became more specific in the updated guideline. Another was the new use of separate male and female thresholds for the CHADS-VASc score in the guideline.”

Regardless of whether it is persistent or periodic, or symptomatic or silent, AF places patients at significantly higher risk of stroke. The risk from AF is 5-fold alone. When mitral stenosis is involved, the risk increases by 20 times over. Atrial flutter, the guidelines for which were also adjusted, also increases patients’ risk of stroke.

The update makes various adjustments to the formula used in making decisions to select an anticoagulation agent. The guidelines call for shared decision-making that includes not only clinical characteristics but risk factors, cost, patient preference, drug interactions, and other factors.

The criteria clarify that patients with moderate or severe mitral stenosis are excluded from taking direct oral anticoagulants (DOACs), which include dagibatran (Pradaxa), apixaban (Eliquis), and exdoxaban (Lixiana) instead of warfarin. In other cases of AF, DOACs may be the better choice for preventing stroke and systemic embolism and are associated with lower risk of major bleeding.

The guidelines include performance measures (PM) in 5 areas:

  • CHA2DS2-VASc risk score (used for calculating stroke risk for AF patients) documented prior to discharge
  • anticoagulation prescribed prior to discharge
  • prothrombin time/international normalized ratio planned follow-up documented prior to discharge for warfarin treatment
  • CHA2DS2-VASc risk score documented during outpatient encounter
  • anticoagulation prescribed during outpatient encounter

References

  1. 2020 Update to the 2016 ACC/AHA clinical performance and quality measures for adults with atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol 2020; published online December 7, 2020. https://www.jacc.org/doi/10.1016/j.jacc.2020.08.037
  2. Craig TJ, Wann, S, Calkins, H, et al.2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the heart rhythm society in collaboration with the society of thoracic surgeons. Circulation 2019;140:e125–e151. https://doi.org/10.1161/CIR.0000000000000665