From the Guidelines
Xarelto is not contraindicated in patients with non-rheumatic mitral and tricuspid regurgitation, and can be used as an anticoagulant option in these patients, as supported by the 2018 European Heart Rhythm Association practical guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation 1.
Key Points to Consider
- The 2018 European Heart Rhythm Association guide indicates that mild to moderate other native valvular disease, such as mild-moderate aortic stenosis or regurgitation, degenerative mitral regurgitation, and other non-rheumatic valve conditions, are eligible for non-vitamin K antagonist oral anticoagulant (NOAC) therapy, including Xarelto 1.
- The distinction between valvular and non-valvular heart disease is crucial for anticoagulant selection, with Xarelto being contraindicated in patients with mechanical heart valves and moderate to severe mitral stenosis of rheumatic origin, but not for regurgitation of the mitral or tricuspid valves 1.
- If anticoagulation is needed for patients with non-rheumatic mitral and tricuspid regurgitation, such as for atrial fibrillation, Xarelto can be prescribed at standard dosing, typically 20 mg once daily with food for patients with normal renal function, or 15 mg once daily for those with reduced renal function (CrCl 15-50 mL/min) 1.
Important Considerations for Anticoagulant Selection
- The EHRA Type 2 valvular heart disease classification refers to patients with native valvular stenoses and insufficiencies, including mitral valve repair, bioprosthetic valve replacements, and transaortic valve intervention (TAVI), who may be eligible for NOAC therapy, including Xarelto 1.
- Patients with biological valves or after valve repair constitute a grey area, but the use of a NOAC for the management of concomitant atrial fibrillation is considered a valid option, except for AF in the presence of a biological mitral prosthesis implanted for rheumatic mitral stenosis, where VKA may be preferred 1.
From the Research
Xarelto Contraindications
- Xarelto (rivaroxaban) is a direct factor Xa inhibitor used for the prevention of stroke and systemic embolism in patients with atrial fibrillation (AF) 2.
- The studies provided do not directly address the contraindication of Xarelto in patients with non-rheumatic mitral and tricuspid regurgitation.
Valve Disease and Xarelto
- A study analyzing data from the ROCKET AF trial found that patients with significant valvular disease, including native mitral and aortic valve disease, had a similar rate of stroke or systemic embolism with rivaroxaban compared to warfarin 3.
- However, the same study found that patients with significant valvular disease had a higher rate of major and non-major clinically relevant bleeding with rivaroxaban compared to warfarin.
Mitral Regurgitation and Stroke Risk
- A study analyzing data from the CardioCHUVI-AF registry found that mitral regurgitation (MR) grade was not associated with a reduced risk of stroke in patients with non-rheumatic AF 4.
- The study found that the incidence of stroke was similar between patients with and without significant MR.
Xarelto Use in Patients with Valve Disease
- While the studies provided do not directly address the contraindication of Xarelto in patients with non-rheumatic mitral and tricuspid regurgitation, they suggest that Xarelto may be used in patients with valve disease, including those with significant valvular disease 3.
- However, the decision to use Xarelto in these patients should be made on a case-by-case basis, taking into account the individual patient's risk factors and potential benefits and risks of treatment 5.