BACKGROUND: Despite proven efficacy and safety of direct oral anticoagulants (DOACs) over warfarin in patients with atrial fibrillation (AF), data on patients with AF and valvular heart disease remain scarce. We aimed to evaluate the DOACs compared with warfarin among patients with AF and valvular heart disease.

METHODS AND RESULTS: We conducted a retrospective cohort study of patients ≥18 years of age, who had AF and valvular heart disease, and were new users of DOACs or warfarin. The primary effectiveness outcomes were ischemic stroke or systemic embolism, and bleeding for safety. We used Cox proportional-hazards regression after propensity score matching to estimate hazard ratios (HRs) and 95% CIs. In the matched cohort, DOAC use (versus warfarin) was associated with a lower rate of ischemic stroke or systemic embolism (HR, 0.70 [95% CI, 0.61-0.81]) and bleeding (HR, 0.72 [95% CI, 0.65-0.80]). We found a lower rate of ischemic stroke or systemic embolism with rivaroxaban (HR, 0.74 [95% CI, 0.62-0.89]) and apixaban (HR, 0.62 [95% CI, 0.52-0.74]) but not dabigatran (HR, 0.89 [95% CI, 0.63-1.26]). We found a lower rate of bleeding with rivaroxaban (HR, 0.84 [95% CI, 0.74-0.95]), apixaban (HR, 0.60 [95% CI, 0.53-0.68]), dabigatran (HR, 0.75 [95% CI, 0.58-0.97]), and edoxaban (HR, 0.21 [95% CI, 0.05-0.83]). We were unable to obtain estimates for the effectiveness outcome with edoxaban due to the small number of events.

CONCLUSIONS: In this study of patients with AF and valvular heart disease, DOAC treatment was associated with a lower risk of ischemic stroke or systemic embolism and bleeding compared with warfarin.