Anticoagulation in Patients with Aortic Stenosis and Atrial Fibrillation

There is a rising prevalence of patients with coexisting valvular heart disease (VHD) and atrial fibrillation (AF). Anti-coagulating these patients is often a clinical challenge, as they pose a greater bleeding risk on treatment than patients without VHD, and a greater risk of stroke or systemic embolism if anticoagulation is withheld. Patients with aortic stenosis (AS), in particular, have the highest rates of stroke and bleeding risk amongst VHD subtypes. Data comparing direct oral anticoagulants (DOAC) to Warfarin in patients with various VHD subtypes and AF are limited. Available post-hoc analysis has shown that Rivaroxaban may be associated with more major bleeding when used in patients with AS, mitral regurgitation (MR), or aortic regurgitation (AR), but similar rates of stroke or systemic embolism compared to Warfarin. Apixaban was found to have comparable outcomes with Warfarin in patients with AS, MR, or AR. Although Dabigatran and Edoxaban have similar safety and efficacy profiles to Warfarin in VHD patients, there are no available outcome data by valve disease subtype, particularly AS, which is the focus of our review. Further well-powered randomized trials evaluating various oral anticoagulant regimens are needed for the growing population of patients with AS and AF.