When rheumatic heart disease is complicated by atrial fibrillation or atrial flutter, the arrhythmia substantially raises the risk of thromboembolic events, including stroke. The co-existence of underlying valvular pathology — in particular the extent of mitral valve involvement — directly influences how management is structured in this population.
Anticoagulation for stroke prevention is the cornerstone of management in this setting, with the choice of anticoagulant strategy informed by the nature and severity of the valvular disease. Rate or rhythm control strategies are also part of the clinical picture, depending on individual patient factors.
DOI: 10.1161/CIR.0000000000000921
Anticoagulation with oral vitamin K antagonists or direct thrombin or factor Xa inhibitors (direct-acting oral anticoagulants) is recommended for stroke prevention when there is atrial fibrillation or atrial flutter.
However, it is unknown whether direct-acting oral anticoagulants are efficacious in patients with moderate to severe rheumatic mitral valve stenosis because these patients were excluded from the randomized clinical trials of direct-acting oral anticoagulants.
Efficacy and superiority of rhythm control over rate control with nondihydropyridine calcium channel blockers or β-blockers for treatment of symptomatic atrial fibrillation and maintenance of sinus rhythm have been demonstrated in small, single-center randomized trials using either electric and pharmacological (usually amiodarone) cardioversion or catheter ablation in addition to valvular interventions when indicated, but these strategies are not generalizable to all patients and may not be readily available or affordable in LMICs.
View source ↗