Author + information
- Received April 14, 2020
- Revision received July 2, 2020
- Accepted July 4, 2020
- Published online August 28, 2020.
- Line Melgaard, MSc, PhDa,b,∗ (, )
- Thure Filskov Overvad, MD, PhDa,b,
- Martin Jensen, MScb,
- Gregory Y.H. Lip, MDb,c,∗,
- Torben Bjerregaard Larsen, MD, PhDa,b,∗ and
- Peter Brønnum Nielsen, MSc, PhD, MPHa,b,∗
- aDepartment of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- bAalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
- cLiverpool Centre for Cardiovascular Sciences, University Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- ↵∗Address for correspondence:
Dr. Line Melgaard, Department of Cardiology, Aalborg University Hospital, Sdr. Skovvej 15, Aalborg DK-9000, Denmark.
Objectives The authors sought to describe the risk of thromboembolism in non-anticoagulated atrial fibrillation patients with Evaluated Heartvalves, Rheumatic or Artificial (EHRA) Type 2 valvular heart disease (VHD) <65 or 65 to 74 years of age and with 0 or 1 non-sex comorbidity of the CHA2DS2-VASc score.
Background A minor, but important, proportion of patients with atrial fibrillation and VHD beyond moderate-to-severe mitral stenosis and/or a mechanical prosthetic valve, so-called EHRA Type 2 VHD, have 0 or 1 coexisting non-sex comorbidities of the CHA2DS2-VASc score, and are therefore not strongly recommended oral anticoagulant therapy according to guidelines. Whether these patients are truly low risk of thromboembolism has not been investigated.
Methods This was a cohort study of 55,613 patients identified in nationwide Danish registries from 2000 to 2018, of which 1,907 patients had EHRA Type 2 VHD. Risk of thromboembolism after 1 and 5 years of follow-up were calculated.
Results At 1 year after atrial fibrillation diagnosis, patients with EHRA Type 2 VHD had a risk of thromboembolism between 1.2% and 1.5%, according to age group (<65 or 65 to 74 years of age), and number of non-sex comorbidities of the CHA2DS2-VASc score (0 or 1). Interestingly, in patients with EHRA Type 2 VHD <65 years of age with 0 or 1 comorbidity, the risk was 1.5% (95% confidence interval: 0.7% to 2.8%) and 1.5% (95% confidence interval: 0.6% to 3.4%) at 1 year after the atrial fibrillation diagnosis.
Conclusions These observations suggest that in atrial fibrillation patients with EHRA Type 2 VHD, who are not currently recommended oral anticoagulant therapy according to guidelines, the risk of thromboembolism may exceed the level above which oral anticoagulation is considered beneficial.
↵∗ Drs. Lip, Larsen, and Nielsen contributed equally to this work and are joint senior authors.
The study was supported by “The BMS/Pfizer European Thrombosis Investigator Initiated Research Program (ERISTA) 2018” and the Obel Family Foundation. Dr. Melgaard has received grant support from BMS/Pfizer. Prof. Lip has been a consultant for Bayer/Janssen, BMS/Pfizer, Biotronik, Medtronic, Boehringer Ingelheim, Microlife, and Daiichi Sankyo; and has been a speaker for Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim, Microlife, Roche, and Daiichi Sankyo. No fees were received personally. Prof. Larsen has been an investigator for Janssen Scientific Affairs, LLC, and Boehringer Ingelheim; and has been a speaker for Bayer, BMS/Pfizer, Janssen Pharmaceuticals, Takeda, Roche Diagnostics, and Boehringer Ingelheim. No fees were received personally. Dr. Nielsen has received speaking fees Boehringer Ingelheim; consulting fees from Bayer; and grant support from BMS/Pfizer. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received April 14, 2020.
- Revision received July 2, 2020.
- Accepted July 4, 2020.
- 2020 American College of Cardiology Foundation
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