Institute of Cardiovascular Sciences, University of Birmingham and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark.
Sorbonne Université Paris 6, ACTION Study Group, Institut De Cardiologie, Groupe Hôpital Pitié-Salpetrière (APHP), INSERM UMRS 1166, Paris, France.
Europace. 2017 Nov 1;19(11):1757-1758. doi: 10.1093/europace/eux240.
Atrial fibrillation (AF) is a major worldwide public health problem, and AF in association with valvular heart disease (VHD) is also common. However, management strategies for this group of patients have been less informed by randomized trials, which have largely focused on 'non-valvular AF' patients. Thrombo-embolic risk also varies according to valve lesion and may also be associated with CHA2DS2VASc score risk factor components, rather than only the valve disease being causal. Given marked heterogeneity in the definition of valvular and non-valvular AF and variable management strategies, including non-vitamin K antagonist oral anticoagulants (NOACs) in patients with VHD other than prosthetic heart valves or haemodynamically significant mitral valve disease, there is a need to provide expert recommendations for professionals participating in the care of patients presenting with AF and associated VHD. To address this topic, a Task Force was convened by the European Heart Rhythm Association (EHRA) and European Society of Cardiology (ESC) Working Group on Thrombosis, with representation from the ESC Working Group on Valvular Heart Disease, Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), South African Heart (SA Heart) Association and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE) with the remit to comprehensively review the published evidence, and to publish a joint consensus document on the management of patients with AF and associated VHD, with up-to-date consensus recommendations for clinical practice for different forms of VHD. This consensus document proposes that the term 'valvular AF' is outdated and given that any definition ultimately relates to the evaluated practical use of oral anticoagulation (OAC) type, we propose a functional Evaluated Heartvalves, Rheumatic or Artificial (EHRA) categorization in relation to the type of OAC use in patients with AF, as follows: (i) EHRA Type 1 VHD, which refers to AF patients with 'VHD needing therapy with a Vitamin K antagonist (VKA); and (ii) EHRA Type 2 VHD, which refers to AF patients with 'VHD needing therapy with a VKA or a Non-VKA oral anticoagulant (NOAC)', also taking into consideration CHA2DS2VASc score risk factor components. This consensus document also summarizes current developments in the field, and provides general recommendations for the management of these patients based on the principles of evidence-based medicine.
心房颤动（AF）是一个全球性的重大公共卫生问题，AF 合并瓣膜性心脏病（VHD）也很常见。然而，针对这组患者的管理策略较少受到随机试验的影响，这些试验主要集中在“非瓣膜性 AF”患者。血栓栓塞风险也因瓣膜病变而异，也可能与 CHA2DS2VASc 评分危险因素成分有关，而不仅仅是瓣膜疾病是病因。鉴于瓣膜性和非瓣膜性 AF 的定义存在明显的异质性，以及管理策略的多样性，包括非维生素 K 拮抗剂口服抗凝剂（NOAC）在除人工心脏瓣膜或有临床意义的二尖瓣疾病以外的 VHD 患者中的应用，因此需要为参与治疗 AF 合并 VHD 患者的专业人员提供专家建议。为了解决这个问题，由欧洲心律协会（EHRA）和欧洲心脏病学会（ESC）血栓工作组召集了一个工作组，代表 ESC 瓣膜性心脏病工作组、心律学会（HRS）、亚太心律学会（APHRS）、南非心脏协会（SA Heart）和拉丁美洲心脏刺激和电生理学学会（SOLEACE），全面审查已发表的证据，并发布一份关于 AF 合并 VHD 患者管理的联合共识文件，为不同形式的 VHD 提供最新的临床实践共识建议。这份共识文件提出，“瓣膜性 AF”这一术语已经过时，鉴于任何定义最终都与口服抗凝剂（OAC）类型的评估实用价值有关，因此我们建议根据 AF 患者 OAC 使用类型对心脏瓣膜、风湿性或人工（EHRA）进行功能分类，如下所示：（i）EHRA 1 型 VHD，指的是“需要维生素 K 拮抗剂（VKA）治疗的 VHD 的 AF 患者”；（ii）EHRA 2 型 VHD，指的是“需要 VKA 或非维生素 K 拮抗剂口服抗凝剂（NOAC）治疗的 VHD 的 AF 患者”，同时还考虑了 CHA2DS2VASc 评分危险因素成分。这份共识文件还总结了该领域的最新进展，并根据循证医学原则为这些患者的管理提供了一般建议。
