Anticoagulation in Atrial Fibrillation and Rheumatic Heart Disease

This editorial reviews the INVICTUS trial, a randomized study evaluating oral anticoagulants in patients with atrial fibrillation and rheumatic heart disease. The trial compared rivaroxaban a direct oral anticoagulant (DOAC) against vitamin K antagonists (VKAs), with 4565 participants, 85% of whom had moderate-to-severe mitral stenosis. Rivaroxaban failed to show noninferiority to VKAs; the DOAC group experienced higher rates of stroke and death without any reduction in major bleeding. Mortality differences were largely due to fewer deaths from mechanical pump failure and sudden death in the VKA group. The editorial discusses the limits of DOACs in valvular AF, particularly in rheumatic heart disease, and endorses VKAs as the preferred strategy. It highlights that better outcomes are likely linked not just to anticoagulation choice, but to more frequent physician contact, improved therapeutic range monitoring, and holistic care. Emphasis is placed on the ABC (Atrial Fibrillation Better Care) pathway, integrating anticoagulation, symptom control, and comorbidity management. The authors advocate individualized treatment and structured, integrated care to improve stroke prevention and survival.

This editorial reviews the INVICTUS trial, a randomized study evaluating oral anticoagulants in patients with atrial fibrillation and rheumatic heart disease. The trial compared rivaroxaban a direct oral anticoagulant (DOAC) against vitamin K antagonists (VKAs), with 4565 participants, 85% of whom had moderate-to-severe mitral stenosis. Rivaroxaban failed to show noninferiority to VKAs; the DOAC group experienced higher rates of stroke and death without any reduction in major bleeding. Mortality differences were largely due to fewer deaths from mechanical pump failure and sudden death in the VKA group. The editorial discusses the limits of DOACs in valvular AF, particularly in rheumatic heart disease, and endorses VKAs as the preferred strategy. It highlights that better outcomes are likely linked not just to anticoagulation choice, but to more frequent physician contact, improved therapeutic range monitoring, and holistic care. Emphasis is placed on the ABC (Atrial Fibrillation Better Care) pathway, integrating anticoagulation, symptom control, and comorbidity management. The authors advocate individualized treatment and structured, integrated care to improve stroke prevention and survival.