Key result
Atrial fibrillation with concomitant aortic stenosis was associated with an increased risk of stroke, systemic embolism, and mortality compared to AF without VHD (HR 1.27; 95% CI 1.19-1.37).
Why the study?
To evaluate electronic health record definitions of atrial fibrillation and valvular heart disease subtypes, time trends in prevalence, and prognosis.
Does concomitant valvular heart disease increase the risk of stroke, systemic embolism, and mortality in patients with atrial fibrillation?
Cohort (n=76,019)
Yes
Does concomitant valvular heart disease increase the risk of stroke, systemic embolism, and mortality in patients with atrial fibrillation?
Hazard Ratio: 1.27 (95% CI 1.19–1.37)
Concomitant valvular heart disease, particularly aortic stenosis, mitral stenosis, or mechanical valves, significantly increases the risk of stroke, systemic embolism, and mortality in patients with atrial fibrillation.
May warrant enhanced thromboembolism monitoring in AF with aortic stenosis; leaves open whether valve intervention modifies risk.
AIMS: To evaluate population-based electronic health record (EHR) definitions of atrial fibrillation (AF) and valvular heart disease (VHD) subtypes, time trends in prevalence and prognosis. METHODS AND RESULTS: A total of 76 019 individuals with AF were identified in England in 1998-2010 in the CALIBER resource, linking primary and secondary care EHR. An algorithm was created, implemented, and refined to identify 18 VHD subtypes using 406 diagnosis, procedure, and prescription codes. Cox models were used to investigate associations with a composite endpoint of incident stroke (ischaemic, haemorrhagic, and unspecified), systemic embolism (SSE), and all-cause mortality. Among individuals with AF, the prevalence of AF with concomitant VHD increased from 11.4% (527/4613) in 1998 to 17.6% (7014/39 868) in 2010 and also in individuals aged over 65 years. Those with mechanical valves, mitral stenosis (MS), or aortic stenosis had highest risk of clinical events compared to AF patients with no VHD, in relative [hazard ratio (95% confidence interval): 1.13 (1.02-1.24), 1.20 (1.05-1.36), and 1.27 (1.19-1.37), respectively] and absolute (excess risk: 2.04, 4.20, and 6.37 per 100 person-years, respectively) terms. Of the 95.2% of individuals with indication for warfarin (men and women with CHA2DS2-VASc ≥1 and ≥2, respectively), only 21.8% had a prescription 90 days prior to the study. CONCLUSION: Prevalence of VHD among individuals with AF increased from 1998 to 2010. Atrial fibrillation associated with aortic stenosis, MS, or mechanical valves (compared to AF without VHD) was associated with an excess absolute risk of stroke, SSE, and mortality, but anticoagulation was underused in the pre-direct oral anticoagulant (DOAC) era, highlighting need for urgent clarity regarding DOACs in AF and concomitant VHD.
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Banerjee et al. (2019) conducted a cohort in Atrial fibrillation with concomitant valvular heart disease (n=76,019). Concomitant valvular heart disease (e.g., aortic stenosis) vs. Atrial fibrillation without valvular heart disease was evaluated on Composite of incident stroke (ischaemic, haemorrhagic, and unspecified), systemic embolism (SSE), and all-cause mortality (HR 1.27, 95% CI 1.19-1.37). Atrial fibrillation with concomitant aortic stenosis was associated with an increased risk of stroke, systemic embolism, and mortality compared to AF without VHD (HR 1.27; 95% CI 1.19-1.37).
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