Direct Oral Anticoagulants in Valvular Atrial Fibrillation

Definition and Eligibility

The European Society of Cardiology recommends that DOACs are cleared and recommended for most patients with valvular AF, except those with mechanical heart valves or moderate-to-severe mitral stenosis, who must remain on warfarin 1, 2
Absolute contraindications for DOACs include mechanical prosthetic heart valves and moderate-to-severe rheumatic mitral stenosis 1, 2
DOAC-eligible valvular conditions include native aortic stenosis, aortic regurgitation, mitral regurgitation, mild mitral stenosis, bioprosthetic valves, and prior valve repair 2

The American Heart Association and American College of Cardiology recommend DOACs in preference to warfarin for AF patients with native aortic valve disease, mitral regurgitation, tricuspid valve disease, bioprosthetic heart valves, prior surgical valve repair, and hypertrophic cardiomyopathy with AF 1, 2, 4
The European Society of Cardiology provides Class I, Level A evidence that DOACs should be preferred over VKAs in these populations, demonstrating a 50% reduction in intracranial hemorrhage compared to warfarin 1

Warfarin remains the only option for patients with mechanical prosthetic heart valves and moderate-to-severe rheumatic mitral stenosis 1, 2

The European Heart Journal recommends identifying valve pathology and assessing CHA₂DS₂-VASc score to determine the need for DOACs or warfarin 1, 2, 5
The European Society of Cardiology recommends selecting the appropriate DOAC and dose based on renal function and applying DOAC-specific dose reduction criteria 1, 3, 6

The American Heart Association and American College of Cardiology note that while DOACs are reasonable alternatives to warfarin in patients with bioprosthetic valves and AF, this is based on subgroup analyses rather than dedicated trials 2
The European Society of Cardiology supports DOAC use in patients with bioprosthetic valves with Class IIa, Level C-LD evidence 2