Key result
DOACs linked to ~72% fewer thromboembolic events vs warfarin in mitral stenosis and AF.
Why the study?
Patients with mitral stenosis and AF require anticoagulation for stroke prevention, but prior DOAC studies excluded patients with moderate to severe mitral stenosis.
Does direct oral anticoagulant (DOAC) use reduce ischemic strokes or systemic embolisms compared to warfarin in patients with atrial fibrillation and mitral stenosis?
Cohort (n=2,230)
Does direct oral anticoagulant (DOAC) use reduce ischemic strokes or systemic embolisms compared to warfarin in patients with atrial fibrillation and mitral stenosis?
Hazard Ratio: 0.28 (95% CI 0.18–0.45)
Absolute Event Rate: 2.22% vs 4.19%
In patients with atrial fibrillation and mitral stenosis, off-label DOAC use was associated with a significantly lower risk of thromboembolic events compared to warfarin, without an increase in intracranial hemorrhage.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Given the paucity of information regarding the use of DOACs in patients with MS, these observational data are welcome and should be viewed as hypothesis-generating.”
“Our study is the first one which addresses the results of DOAC [therapy] in patients with atrial fibrillation and mitral stenosis. There is a paucity of data even for warfarin in patients with atrial fibrillation and mitral stenosis.”
“I think given this current study and given the data to date, we can't jump to that conclusion just yet, that DOACs are okay for all cases of mitral stenosis and A-fib.”
Supports DOAC preference over warfarin for stroke prevention in mitral stenosis with AF; extends evidence to this valvular population.
BACKGROUND Patients with mitral stenosis and atrial fibrillation (AF) require anticoagulation for stroke prevention. Thus far, all studies on direct oral anticoagulants (DOACs) have excluded patients with moderate to severe mitral stenosis. OBJECTIVES The aim of this study was to validate the efficacy of DOACs in patients with mitral stenosis. METHODS The study population was enrolled from the Health Insurance Review and Assessment Service (HIRA) database in the Republic of Korea, and it included patients who were diagnosed with mitral stenosis and AF and either were prescribed DOACs for off-label use or received conventional treatment with warfarin. The primary efficacy endpoint was ischemic strokes or systemic embolisms, and the safety outcome was intracranial hemorrhage. RESULTS A total of 2,230 patients (mean age 69.7 ± 10.5 years; 682 [30.6%] males) were included in the present study. Thromboembolic events occurred at a rate of 2.22%/year in the DOAC group, and 4.19%/year in the warfarin group (adjusted hazard ratio for DOAC: 0.28; 95% confidence interval: 0.18 to 0.45). Intracranial hemorrhage occurred in 0.49% of the DOAC group and 0.93% of the warfarin group (adjusted hazard ratio for DOAC: 0.53; 95% confidence interval: 0.22 to 1.26). CONCLUSIONS In patients with AF accompanied with mitral stenosis, DOAC use is promising and hypothesis generating in preventing thromboembolism. Our results need to be replicated in a randomized trial.
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Kim et al. (2019) conducted a cohort in Mitral stenosis and atrial fibrillation (n=2,230). Direct oral anticoagulants (DOACs) vs. Warfarin was evaluated on Ischemic strokes or systemic embolisms (HR 0.28, 95% CI 0.18 to 0.45). DOAC use was associated with a lower rate of thromboembolic events compared to warfarin in patients with mitral stenosis and atrial fibrillation (adjusted HR 0.28; 95% CI 0.18-0.45).
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