Anticoagulation in Mitral Stenosis

Classification of Valvular Disease for Anticoagulant Choice

The European Heart Rhythm Association (EHRA) classifies valvulopathies into two fundamental categories to guide anticoagulant therapy, with EHRA Type 1 being a contraindication to DOACs, including moderate to severe mitral stenosis and mechanical valves 1, 3
The EHRA classification is used to determine the eligibility of patients for DOACs, with EHRA Type 2 including conditions such as mitral insufficiency, aortic stenosis, and bioprosthetic valves 2, 3

The American College of Chest Physicians recommends VKAs (Grade 1A) for patients with rheumatic mitral valve disease complicated by atrial fibrillation, with a target INR of 2.5 (range 2.0-3.0) 4, 5, 8
For patients with moderate to severe mitral stenosis and atrial fibrillation, VKAs are the only recommended option, with a target INR of 2.5 (range 2.0-3.0) 4, 5, 6, 7

In patients with rheumatic mitral valve disease in sinus rhythm, the use of VKAs is recommended if the left atrial diameter is ≥55 mm, with a target INR of 2.5 4, 5
The presence of left atrial thrombus is an indication for mandatory VKA use (Grade 1A) 4, 5

For patients with moderate to severe mitral stenosis and atrial fibrillation, VKAs should be used with a target INR of 2.5 (range 2.0-3.0) 4, 5, 6
For patients with mild mitral stenosis or mitral insufficiency, DOACs are preferred over VKAs, with the calculation of the CHA₂DS₂-VASc score (excluding valvulopathy from the score) to determine the indication for anticoagulation 2, 3

The distinction between mitral stenosis and mitral insufficiency is crucial, as only moderate to severe mitral stenosis is a contraindication to DOACs, while mitral insufficiency of any degree allows the use of DOACs 2
The term "non-valvular atrial fibrillation" is obsolete and should not be used, as it does not reflect current EHRA classifications 2

For patients with left atrial thrombus who are candidates for percutaneous mitral balloon valvuloplasty (PMBV), the procedure should be postponed and VKAs should be administered with a target INR of 3.0 (range 2.5-3.5) until the thrombus is resolved, as documented by repeated transesophageal echocardiography (Grade 1A) 4, 5