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Impact of valvular heart disease on oral anticoagulant therapy in non-valvular atrial fibrillation: results from the RAMSES study

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Abstract

The definition of non-valvular atrial fibrillation (NVAF) is controversial. We aimed to assess the impact of valvular heart disease on stroke prevention strategies in NVAF patients. The RAMSES study was a multicenter and cross-sectional study conducted on NVAF patients (ClinicalTrials.gov identifier NCT02344901). The study population was divided into patients with significant valvular disease (SVD) and non-significant valvular disease (NSVD), whether they had at least one moderate valvular disease or not. Patients with a mechanical prosthetic valve and mitral stenosis were excluded. Baseline characteristics and oral anticoagulant (OAC) therapies were compared. In 5987 patients with NVAF, there were 3929 (66%) NSVD and 2058 (34%) SVD patients. The predominant valvular disease was mitral regurgitation (58.1%), followed by aortic regurgitation (24.1%) and aortic stenosis (17.8%). Patients with SVD had higher CHA2DS2VASc [3.0 (2.0; 4.0) vs. 4.0 (2.0; 5.0), p < 0.001] and HAS-BLED [2.0 (1.0; 2.0) vs. 2.0 (1.0; 2.0), p = 0.004] scores compared to patients with NSVD. Overall, 2763 (71.2%) of NSVD and 1515 (73.8%) of SVD patients were on OAC therapy (p = 0.035). When the patients with SVD were analyzed separately, the mean CHA2DS2VASc and HAS-BLED scores were higher in patients with mitral regurgitation compared to patients with aortic regurgitation and aortic stenosis [4.0 (3.0; 5.0), 3.0 (2.0; 4.0), 3.0 (2.0; 4.0) p < 0.001 and 2.0 (1.0; 3.0), 1.0 (1.0; 2.0), 1.0 (0.0; 2.0) p < 0.001, respectively]. In patients with SVD, 65.7% of mitral regurgitation, 82.6% of aortic regurgitation and 88.0% of aortic stenosis patients were on OAC therapy. One out of three NVAF patients had at least one moderate valvular heart disease with the predominance of mitral regurgitation. Patients with SVD were at greater risk of stroke and bleeding compared to patients with NSVD. Although patients with mitral regurgitation should be given more aggressive anticoagulant therapy due to their higher risk of stroke, they are undertreated compared to patients with aortic valve diseases.

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Acknowledgements

The authors would like to thank Ekrem Bilal Karaayvaz, MD, Bağcılar Education and Research Hospital, Department of Cardiology, Mevlut Koc, MD, Assoc. Prof, Adana Numune Education and Research Hospital, Department of Cardiology, Durmus Yıldıray Şahin, MD, Assoc. Prof, Adana Numune Education and Research Hospital, Department of Cardiology, Tolga Çimen, MD, Dışkapı Yıldırım Beyazıt Education and Research Hospital, Department of Cardiology, Tolga Sinan Güvenç, MD, Siyami Ersek Heart Education and Research Hospital, Department of Cardiology, Nihat Pekel, MD, Assist Prof, İzmir Medikal Park Hospital, Department of Cardiology, Kerem Temel, MD, Acıbadem Eskişehir Hospital, Department of Cardiology, Vehip Keskin, MD, Muğla Private Cardiology Clinic, for their contribution to the study.

The collaborators of the study

Fatma Özpamuk Karadeniz, MD (Şanlıurfa Balıklıgöl State Hospital, Department of Cardiology), Ahmet İlker Tekkesin, MD (Siyami Ersek Heart Education and Research Hospital, Department of Cardiology), Yasin Çakıllı, MD (Tuzla State Hospital, Department of Cardiology), Ceyhan Türkkan, MD (Siyami Ersek Heart Education and Research Hospital, Department of Cardiology), Mehmet Hamidi, MD (Bandırma State Hospital, Department of Cardiology), Vahit Demir, MD (Yozgat State Hospital, Department of Cardiology), Mustafa Ozan Gürsoy, MD (Gaziemir State Hospital, Department of Cardiology), Müjgan Tek Öztürk, MD (Ankara Keçiören Education and Research Hospital, Department of Cardiology), Gökhan Aksan, MD (Şişli Hamidiye Etfal Education and Research Hospital, Department of Cardiology), Sabri Seyis, MD (Mersin Private Dogus Hospital, Department of Cardiology), Mehmet Ballı, MD (Mersin Toros State Hospital, Department of Cardiology), Mehmet Hayri Alıcı, MD (Gaziantep 25 Aralık State Hospital, Department of Cardiology), Serdar Bozyel, MD (Kocaeli Derince Education and Research Hospital, Department of Cardiology), Ibrahim Altun, MD, Assist. Prof. (Mugla Sitki Kocman University, Faculty of Medicine, Department of Cardiology), Feyza Çalık, MD (Mersin State Hospital, Department of Cardiology), Oğuz Karaca, MD, Assist. Prof. (İstanbul Medipol Üniversity Faculty of Medicine, Department of Cardiology), Füsun Helvacı, MD (Şişli Hamidiye Etfal Education and Research Hospital, Department of Cardiology), Kadriye Akay, MD (Kocaeli State Hospital, Department of Cardiology), Yiğit Çanga, MD (Kartal Yavuz Selim State Hospital, Department of Cardiology), Savaş Çelebi, MD (TOBB ETÜ Hospital, Department of Cardiology), Emine Altuntas, MD (Bingöl State Hospital, Department of Cardiology), Mehmet Aytürk, MD (Ankara Keçiören Education and Research Hospital, Department of Cardiology), Hacı Murat Güneş, MD, Assist. Prof. (İstanbul Medipol Üniversity Faculty of Medicine, Department of Cardiology), Tahir Bezgin, MD (Gebze Fatih State Hospital, Department of Cardiology), Aytekin Aksakal, MD (Samsun Education and Research Hospital, Department of Cardiology), Beytullah Çakal, MD, Assist. Prof. (Siyami Ersek Heart Education and Research Hospital, Department of Cardiology), Ayşe Çolak, MD (Mut State Hospital, Department of Cardiology), Özgür Kaplan, MD (Malatya State Hospital, Department of Cardiology), Adem Tatlısu, MD (Sivas Numune State Hospital, Department of Cardiology), Gökhan Gözübüyük, MD (Malatya State Hospital, Department of Cardiology), Selami Demirelli, MD (Erzurum Bölge Education and Research Hospital, Department of Cardiology), Adnan Kaya, MD (Suruç State Hospital, Department of Cardiology), İbrahim Rencüzoğulları, MD, Assist. Prof. (Kafkas University Faculty of Medicine, Department of Cardiology), Zübeyde Bayram, MD (Kartal Yavuz Selim State Hospital, Department of Cardiology), Zeki Şimşek, MD (Kartal Yavuz Selim State Hospital, Department of Cardiology), Murat Civan, MD (İstanbul Private Liv Hospital, Department of Cardiology), Ulaankhu Batgharel, MD (Acıbadem Private Hospital, Department of Cardiology), Ali Ekber Ata, MD (Samsun Medikal Park Hospital, Department of Cardiology), Gökhan Göl, MD (Süreyyapaşa Education and Research Hospital, Department of Cardiology), Gurbet Özge Mert, MD (Mugla Sitki Kocman University, Faculty of Medicine, Department of Cardiology), Kadir Ugur Mert, MD (Mugla Sitki Kocman University, Faculty of Medicine, Department of Cardiology), Aleks Değirmencioğlu, MD (İstanbul Acıbadem University Faculty of Medicine, Department of Cardiology), Özkan Candan, MD (Uşak State Hospital, Department of Cardiology), Özlem Özcan Çelebi, MD (Private Medicana International Ankara Hospital, Department of Cardiology), Cem Doğan, MD (Malatya State Hospital, Department of Cardiology), Fethi Yavuz, MD (Dr. Ersin Arslan State Hospital, Department of Cardiology), Şeref Ulucan, MD, Assist. Prof. (Mevlana University Faculty of Medicine, Department of Cardiology), Arif Arısoy, MD, Assist. Prof. (Gaziosmanpaşa University Faculty of Medicine, Department of Cardiology), Bingül Dilekçi Şahin, MD (Erzurum Bölge Education and Research Hospital, Department of Cardiology), Emrah Ermiş, MD (Erzurum Bölge Education and Research Hospital, Department of Cardiology), Serkan Gökaslan, MD (İstanbul Haydarpaşa Numune Education and Research Hospital, Department of Cardiology), İdris Pektaş, MD (Mersin University Faculty of Medicine, Department of Cardiology), Aslı Tanındı, MD, Assist. Prof. (Ufuk University Faculty of Medicine, Department of Cardiology), Kamuran Tekin, MD (Batman Bölge State Hospital, Department of Cardiology), Kadriye Memic Sancar, MD (Mugla Sitki Kocman University, Faculty of Medicine, Department of Cardiology), Edip Güvenç Çekiç, MD, Assist. Prof. (Sıtkı Koçman University Faculty of Medicine, Department of Pharmacology), Nesrin Filiz Başaran, MD, Assist. Prof. (Sıtkı Koçman University Faculty of Medicine, Department of Pharmacology).

Author information

Authors and Affiliations

  1. Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman Universitesi Tip Fakultesi, Orhaniye Mah. Haluk Özsoy Cad., 48000, Muğla, Turkey

    Özcan Başaran, Volkan Dogan & Murat Biteker

  2. Department of Cardiology, Faculty of Medicine, Sivas Cumhuriyet University, Sivas, Turkey

    Osman Beton

  3. Department of Cardiology, Kahramanmaraş Necip Fazıl State Hospital, Kahramanmaraş, Turkey

    Mehmet Tekinalp

  4. Department of Cardiology, Trabzon Ahi Evren Chest Cardiovascular Surgery Education and Research Hospital, Trabzon, Turkey

    Ahmet Çağrı Aykan & Ezgi Kalaycıoğlu

  5. Department of Cardiology, Fethiye State Hospital, Muğla, Turkey

    Ismail Bolat

  6. Department of Cardiology, Elazığ Education and Research Hospital, Elazig, Turkey

    Onur Taşar

  7. Department of Cardiology, Burdur State Hospital, Burdur, Turkey

    Özgen Şafak

  8. Department of Cardiology, İskilip Atıf Hoca State Hospital, Iskilip, Turkey

    Macit Kalçık

  9. Department of Cardiology, Samsun Education and Research Hospital, Samsun, Turkey

    Mehmet Yaman

  10. Department of Cardiology, Aksaray State Hospital, Aksaray, Turkey

    Sinan İnci

  11. Department of Cardiology, Diyarbakır Gazi Yaşargil Education and Research Hospital, Diyarbakir, Turkey

    Bernas Altıntaş

  12. Department of Cardiology, Gönen State Hospital, Gönen, Turkey

    Sedat Kalkan

  13. Kartal Kosuyolu Heart Education and Research Hospital, Istanbul, Turkey

    Cevat Kırma

Authors
  1. Özcan Başaran
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  2. Volkan Dogan
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  3. Osman Beton
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  4. Mehmet Tekinalp
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  5. Ahmet Çağrı Aykan
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  6. Ezgi Kalaycıoğlu
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  7. Ismail Bolat
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  8. Onur Taşar
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  9. Özgen Şafak
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  10. Macit Kalçık
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  11. Mehmet Yaman
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  14. Sedat Kalkan
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  15. Cevat Kırma
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  16. Murat Biteker
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Consortia

and Collaborators

  • Fatma Özpamuk Karadeniz
  • , Ahmet İlker Tekkesin
  • , Yasin Çakıllı
  • , Ceyhan Türkkan
  • , Mehmet Hamidi
  • , Vahit Demir
  • , Mustafa Ozan Gürsoy
  • , Müjgan Tek Öztürk
  • , Gökhan Aksan
  • , Sabri Seyis
  • , Mehmet Ballı
  • , Mehmet Hayri Alıcı
  • , Serdar Bozyel
  • , Ibrahim Altun
  • , Feyza Çalık
  • , Oğuz Karaca
  • , Füsun Helvacı
  • , Kadriye Akay
  • , Yiğit Çanga
  • , Savaş Çelebi
  • , Emine Altuntas
  • , Mehmet Aytürk
  • , Hacı Murat Güneş
  • , Tahir Bezgin
  • , Aytekin Aksakal
  • , Beytullah Çakal
  • , Ayşe Çolak
  • , Özgür Kaplan
  • , Adem Tatlısu
  • , Gökhan Gözübüyük
  • , Selami Demirelli
  • , Adnan Kaya
  • , İbrahim Rencüzoğulları
  • , Zübeyde Bayram
  • , Zeki Şimşek
  • , Murat Civan
  • , Ulaankhu Batgharel
  • , Ali Ekber Ata
  • , Gökhan Göl
  • , Gurbet Özge Mert
  • , Kadir Ugur Mert
  • , Aleks Değirmencioğlu
  • , Özkan Candan
  • , Özlem Özcan Çelebi
  • , Cem Doğan
  • , Fethi Yavuz
  • , Şeref Ulucan
  • , Arif Arısoy
  • , Bingül Dilekçi Şahin
  • , Emrah Ermiş
  • , Serkan Gökaslan
  • , İdris Pektaş
  • , Aslı Tanındı
  • , Kamuran Tekin
  • , Kadriye Memic Sancar
  • , Edip Güvenç Çekiç
  •  & Nesrin Filiz Başaran

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The collaborators of the study are listed in "Acknowledegments".

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Başaran, Ö., Dogan, V., Beton, O. et al. Impact of valvular heart disease on oral anticoagulant therapy in non-valvular atrial fibrillation: results from the RAMSES study. J Thromb Thrombolysis 43, 157–165 (2017). https://doi.org/10.1007/s11239-016-1445-1

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