Anticoagulation Management in Rheumatic Heart Disease with Atrial Fibrillation

Recommended Anticoagulation Therapy

• The American College of Cardiology recommends vitamin K antagonists, such as warfarin, as the standard therapy for patients with rheumatic heart disease (RHD) and atrial fibrillation (AF), with a target INR of 2.0-3.0 and regular monitoring at least weekly during initiation and monthly when stable 1
• For patients with RHD and AF who are unable to take oral anticoagulants, aspirin alone is recommended, though it provides less protection against thromboembolism 2

Special Considerations for Anticoagulation

• Renal function should be evaluated before starting any anticoagulant and reassessed at least annually 1
• The American College of Cardiology recommends assessing stroke risk using the CHA₂DS₂-VASc score in patients with RHD and AF 3

Contraindications and Precautions

• DOACs (dabigatran, rivaroxaban, apixaban) are specifically contraindicated in patients with mechanical heart valves or moderate-to-severe mitral stenosis, which are common in RHD 1
• Discontinuing anticoagulation without appropriate bridging in high-risk patients should be avoided 5
• Failing to recognize that guidelines for non-valvular AF do not apply to RHD patients should be avoided, as recommended by the American College of Cardiology and the Stroke journal 3, 4