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Warfarin Only for Rheumatic MS with AF — EECC MCQ

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EasyValvular Heart DiseaseWarfarin Only for Rheumatic MS with AFEECC

A 55-year-old woman with rheumatic mitral stenosis (MVA 1.0 cm²) develops new AF. She is haemodynamically stable but symptomatic. According to the 2024 ESC AF Guidelines, what type of anticoagulation is required?

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Correct answer: A — Warfarin is the ONLY recommended anticoagulant for AF in moderate-to-severe rheumatic mitral stenosis — this is one of only two absolute contraindications to DOAC use (alongside mechanical valves)

The 2024 ESC AF Guidelines specify two absolute contraindications to DOACs: (1) mechanical heart valves; (2) moderate-to-severe rheumatic mitral stenosis. In these populations, warfarin is the ONLY recommended anticoagulant. The rationale for excluding DOACs in rheumatic MS: (1) these patients were excluded from all pivotal DOAC trials (RE-LY, ROCKET-AF, ARISTOTLE, ENGAGE-AF); (2) the thrombogenic mechanism in rheumatic MS (atrial chamber enlargement, endothelial disruption, flow stasis from the obstructed valve) may differ from non-valvular AF; (3) limited observational data suggest potentially higher thromboembolic rates with DOACs in this population. Importantly, 'valvular AF' no longer exists as a general term — the only valve-related DOAC contraindications are these two specific conditions. Bioprosthetic valves, aortic stenosis, and MR are all compatible with DOACs.

Reference: ESC (2024): AF Guidelines