{"id":41810,"date":"2014-02-24T16:37:25","date_gmt":"2014-02-24T21:37:25","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=voices&p=41810"},"modified":"2014-02-27T10:09:51","modified_gmt":"2014-02-27T15:09:51","slug":"what-is-non-valvular-atrial-fibrillation","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2014\/02\/24\/what-is-non-valvular-atrial-fibrillation\/","title":{"rendered":"What Is “Non-Valvular” Atrial Fibrillation?"},"content":{"rendered":"

CardioExchange welcomes this guest post from Dr. Westby Fisher, an electrophysiologist practicing at NorthShore University HealthSystem in Evanston, Illinois, and a Clinical Associate Professor of Medicine at the University of Chicago\u2019s Pritzker School of Medicine. This piece originally appeared on his blog, Dr. Wes<\/a>.<\/em><\/p>\n

With the recent heavy marketing of the relatively new novel oral anticoagulants dabigatran, rivaroxaban, and apixaban, a new marketing phrase has been born: “non-valvular” atrial fibrillation.<\/p>\n

What, exactly, is “non-valvular” atrial fibrillation?<\/p>\n

Is it atrial fibrillation without any valvular heart disease like a teeny, tiny bit of functional mitral insufficiency? Or should doctors “ignore” the degree of mitral insufficiency when prescribing these medications? What about mitral-valve-prolapse patients with severe prolapse?<\/p>\n

Is it atrial fibrillation without the presence of any prosthetic heart valve? What about a valve ring placed when a mitral valve is surgically “repaired?”<\/p>\n

Is it atrial fibrillation without any rheumatic heart disease? What about mild mitral stenosis compared to moderate or severe mitral stenosis? If there’s a difference, what valve area should we use to judge safety of prescribing the novel oral antiocoagulants?<\/p>\n

Or is it some combination of one or more of these above patient groups?<\/p>\n

For doctors who manage patients with atrial fibrillation and are considering if they should offer a novel oral anticoagulant to a patient in lieu of warfarin, this issue is not a trivial question.<\/p>\n

To answer some of these questions, we should turn to the RE-LY<\/a>, Rocket AF<\/a>, and Atristotle Trials<\/a>. But these trials offer only minimal guidance to today’s practicing physicians.<\/p>\n

For instance, in the RE-LY trial, only patients without “history of heart valve disorder (i.e., prosthetic valve or hemodynamically relevant valve disease)” were studied<\/a>. What, exactly, do they mean by “hemodynamically relevant heart valve disease?” Does any valve qualify or just the mitral valve?<\/p>\n

The Rocket AF trial describes<\/a> their “non-valvular” heart disease patients a bit better as those with (1) hemodynamically significant mitral valve stenosis or (2) a prosthetic heart valve (annuloplasty with or without prosthetic ring, commissurotomy and\/or valvuloplasty WERE permitted.) But were mild mitral stenosis patients included? What, exactly, defined “hemodynamically-significant” mitral stenosis patients?<\/p>\n

The Aristotle trial defined<\/a> their excluded valvular heart disease as patients with “moderate or severe mitral stenosis, or conditions other than atrial fibrillation that required anticoagulation (e.g., a prosthetic heart valve).” The reader must assume that surgically-repaired mitral valves were okay, but were they included or excluded from this trial – we’re not sure.<\/p>\n

For doctors on the front line of medicine who might want to prescribe these new drugs to their patients, the term “non-valvular atrial fibrillation” seems to mean different things to different people.<\/p>\n

Common sense would dictate that any patient with mitral stenosis (of any severity, in my opinion \u2014 be it rheumatic or post-surgical) or patients with prior placement of a prosthetic heart valve (either bioprosthetic or mechanical) should not be considered for these agents. But this is just my wild-ass guess. After all, there is no clear consensus on what really defines “non-valvular” atrial fibrillation, especially when we examine the evidence-based data available to doctors on this issue.<\/p>\n

But beyond this, as researchers test new therapies, we should be careful not to coin confusing new marketing terms to describe a complicated constellation of patients. Otherwise, we might risk injuring those we really are trying to help.<\/p>\n","protected":false},"excerpt":{"rendered":"

Wes Fisher attempts to figure out what the latest marketing phrase – non-valvular atrial fibrillation – really means.<\/p>\n","protected":false},"author":1177,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[495,1],"tags":[992,2182,1154,340,1008],"class_list":["post-41810","post","type-post","status-publish","format-standard","hentry","category-anticoagulation-2","category-general","tag-aristotle","tag-non-valvular-atrial-fibrillation","tag-oral-anticoagulants","tag-re-ly","tag-rocket-af"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/41810","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/1177"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=41810"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/41810\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=41810"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=41810"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=41810"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}