Valvular heart disease among non-valvular atrial fibrillation: a misnomer, in search of a new term

This editorial refers to ‘Prognostic value of CHA2DS2-VASc score in patients with ‘non-valvular atrial fibrillation’ and valvular heart disease: the Loire Valley Atrial Fibrillation Project’†, by R. Philippart et al., on page 1822. A 76-year-old male patient with arterial hypertension and moderate aortic stenosis presents with the first episode of atrial fibrillation (AF). His CHA2DS2-VASC score is 3. Can we use the CHA2DS2-VASC score that has been developed in patients with non-valvular AF for assessment of his need for long-term oral anticoagulation? Also, since the underlying trials were done in patients with non-valvular AF, is this patient eligible for a non-vitamin K antagonist (NOAC) or does he have valvular disease and, thus, would need a vitamin K antagonist? These are frequently raised questions among cardiologists. Based on registry data, patients with AF and valve disease are common in clinical practice,1–6 with a higher proportion of these patients among those with permanent than those with paroxysmal or persistent AF1,2 (Table 1). While the prevalence was reported as 21% in the Euro Heart Survey (defined as ‘any type of valve disease’)1 and 24.6% in AFNET (‘non-rheumatic valve disease’),2 it was only 4.2% in the PREvention oF thromboembolic events-European Registry in Atrial Fibrillation (PREFER in AF).6 The aim of the latter registry was to assess the management of AF in European countries after the publication of the 2010 European Society of Cardiology (ESC) Guidelines on AF which preferably addressed non-valvular AF. Thus, there may be a gap between the focus of the guidelines and the situation in clinical practice.