DOACs and rheumatic valvulopathy: always a red light?

Area of Science:

• Cardiology
• Internal Medicine
• Epidemiology

Background:

• Rheumatic heart disease (RHD) remains prevalent in low- and middle-income countries, often affecting the mitral valve.
• Atrial fibrillation (AF) is a frequent complication of RHD, increasing risks of mortality, heart failure, and thromboembolism.

Purpose of the Study:

• To evaluate the optimal oral anticoagulation strategy for patients diagnosed with RHD and AF.
• To assess the efficacy and safety of direct oral anticoagulants (DOACs) compared to vitamin K antagonists (VKAs) in this specific patient population.

Main Methods:

• The INVICTUS trial, a randomized study, compared rivaroxaban (a DOAC) with VKAs in patients with RHD-related AF.
• Outcomes assessed included stroke, systemic embolism, myocardial infarction, and death, alongside bleeding risks.

Main Results:

• Rivaroxaban was found to be inferior to VKAs in preventing major adverse cardiovascular events (stroke, systemic embolism, myocardial infarction, or death).
• The bleeding risk was comparable between rivaroxaban and VKAs.

Conclusions:

• The findings support current international guidelines recommending VKAs for anticoagulation in patients with RHD-related AF.
• DOACs, specifically rivaroxaban, are not recommended as a primary treatment for this patient group due to lower efficacy.