Advances in Neurocardiology: Focus on Anticoagulation for Valvular Heart Disease With and Without Atrial Fibrillation.
Advances in Neurocardiology: Focus on Anticoagulation for Valvular Heart Disease With and Without Atrial Fibrillation.
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DOI：
10.1161/strokeaha.122.039310
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发表时间：
2022-12
期刊：
影响因子：
8.3
通讯作者：
Sposato, Luciano A.
中科院分区：
文献类型：
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作者：
Gurol, M. Edip;Sposato, Luciano A.
二尖瓣狭窄是全球范围内心脏病的重要原因，可分为风湿性和钙化两种主要类型。风湿性二尖瓣狭窄主要发生在低收入和中等收入国家的年轻人中，而非风湿性钙化性二尖瓣狭窄在高收入国家的老年人中更为常见。无房颤的二尖瓣狭窄患者不接受抗凝治疗，卒中风险没有可靠的估计。在没有接受抗凝治疗的二尖瓣狭窄和房颤患者中，卒中风险在5 - 6 / 100患者-年之间，与维生素K拮抗剂（VKA）随机对照试验的安慰剂组报道的6 / 100患者-年相似。11一项大型随机对照试验和一项小型试点随机对照试验比较了以二尖瓣狭窄为主的风湿性VHD患者的DOACs和VKA。INVICTUS III期试验（使用维生素K拮抗剂、利伐沙班或阿司匹林治疗风湿性房颤的研究）纳入了4531例风湿性心瓣膜病合并房颤或心房扑动患者。82%的患者有中度/重度二尖瓣狭窄。2纳入的患者必须满足以下标准中的至少一项：CHA2DS2-VASc评分≥2分，二尖瓣面积< 2 cm2，左房自发回声造影剂或左房血栓。该研究评估了每日20mg利伐沙班在预防卒中、全体性栓塞、心肌梗死和血管性或未知原因死亡方面是否优于VKA。INVICTUS较早终止，因为根据预先计划的盲法中期分析，主要问题已得到令人满意的回答。利伐沙班组的心血管事件和死亡率（主要终点）比VKA组高25%，血管死亡增加29%，缺血性卒中发生率增加53%，主要出血事件没有差异。更高的死亡率
Mitral stenosis is a significant cause of heart disease globally and can be classified into 2 main types, rheumatic and calcific. Rheumatic mitral stenosis is predominant in young individuals living in low-and middle-income countries, whereas nonrheumatic calcific mitral stenosis is more common among elderly individuals in higher income countries. There are no reliable estimates of stroke risk in patients with mitral stenosis without AF not receiving anticoagulants. Stroke risk in patients with mitral stenosis and AF not receiving anticoagulants ranges between of 5 to 6 per 100 patient-years, similar to the 6 per 100 patient-years reported in the placebo arms of vitamin K antagonists (VKA) RCTs for nonvalvular AF. 11 One large RCT and a small pilot RCT compared DOACs and VKAs in patients with rheumatic VHD, predominantly mitral stenosis. The INVICTUS Phase III trial (Investigation of Rheumatic AF Treatment Using Vitamin K Antagonists ‚Rivaroxaban or Aspirin Studies) included 4531 patients with rheumatic valvular disease and AF or atrial flutter. 2 Eighty-two percent of the cohort had moderate/severe mitral stenosis. 2 To be included, patients had to fulfill at least one of the following criteria: a CHA2DS2-VASc score≥ 2 points, a mitral-valve area< 2 cm2, left atrial spontaneous echo contrast, or a left atrial thrombus. The study evaluated whether rivaroxaban 20 mg daily was noninferior to VKA in preventing the composite of stroke, systemic embolism, myocardial infarction, and death from a vascular or unknown cause. INVICTUS was terminated earlier because the primary question had been satisfactorily answered as per a pre-planned blinded interim analysis. The rivaroxaban arm showed a 25% higher rate of the composite of cardiovascular events and death (primary end point) than VKA, with 29% increase in vascular deaths, a 53% higher ischemic stroke rate, and no difference in major bleeding events. Higher rates of death