Can Eliquis (apixaban) be used for valvular atrial fibrillation?

Can Eliquis (Apixaban) Be Used for Valvular Atrial Fibrillation?

No, Eliquis (apixaban) cannot be used for true "valvular" atrial fibrillation, which specifically refers to AF with moderate-to-severe mitral stenosis or mechanical heart valves—these are absolute contraindications. However, apixaban can be used in patients with other forms of valvular heart disease, including mild mitral stenosis, mitral regurgitation, aortic stenosis, aortic regurgitation, and bioprosthetic valves. 1, 2

Understanding "Valvular" vs "Nonvalvular" AF

The terminology has caused significant confusion, but current guidelines provide clear definitions:

• Valvular AF (where apixaban is contraindicated): AF with moderate-to-severe mitral stenosis OR mechanical heart valves 1, 2
• Nonvalvular AF (where apixaban can be used): AF without the above conditions, even if other valvular disease is present 1

This distinction is critical because approximately 20% of patients in NOAC trials had various valvular defects including mild mitral stenosis, mitral regurgitation, aortic stenosis, aortic regurgitation, and tricuspid regurgitation. 1

Absolute Contraindications for Apixaban

Apixaban must NOT be used in:

• Mechanical heart valves: The FDA has issued a specific contraindication based on the RE-ALIGN trial, which showed excessive thrombotic complications (5% stroke rate vs 0% with warfarin) and increased major bleeding (4% vs 2%) when DOACs were used with mechanical valves 2, 3
• Moderate-to-severe mitral stenosis: Common in rheumatic heart disease, these patients require warfarin with target INR 2.0-3.0 2, 3

When Apixaban CAN Be Used

Apixaban is appropriate for AF patients with:

Other Valvular Heart Disease

• Aortic stenosis, aortic regurgitation, mitral regurgitation, tricuspid regurgitation, and mild mitral stenosis 4, 5
• In the ARISTOTLE trial, 4,808 patients (26.4%) had moderate or severe valvular heart disease, and apixaban showed consistent efficacy (HR 0.70 for stroke/systemic embolism) and safety (HR 0.79 for major bleeding) compared to warfarin 5

Bioprosthetic Valves

• Patients with remote bioprosthetic valve implantation (at least 3 months post-implantation) can use apixaban 1, 2
• In ARISTOTLE, 41 patients with bioprosthetic valves showed apixaban was an equitable alternative to warfarin, though numbers were small 1
• A 2019 subanalysis of 104 patients with bioprosthetic valves (73 aortic, 26 mitral, 5 both) showed low event rates with no significant differences between apixaban and warfarin 6

Valve Repair

• 52 patients in ARISTOTLE had prior valve repair (50 mitral, 2 aortic), with consistent safety and efficacy results for apixaban 6

Evidence Quality and Strength

Recent comparative effectiveness data strongly favors apixaban:

• A 2024 network meta-analysis found apixaban demonstrated the most significant reduction in stroke/systemic embolism risk compared to other DOACs and warfarin in valvular AF patients, with the lowest major bleeding risk 7
• A 2021 population-based cohort study of 56,336 matched patients with valvular AF showed apixaban reduced ischemic stroke/systemic embolism (HR 0.54) and major bleeding (HR 0.52) compared to warfarin 8

Clinical Algorithm for Decision-Making

Step 1: Identify the type of valve pathology

• Mechanical valve? → Warfarin only 2, 3
• Moderate-to-severe mitral stenosis? → Warfarin only 2, 3

Step 2: If neither above, assess valve type

• Bioprosthetic valve <3 months post-implant? → Warfarin temporarily 2
• Bioprosthetic valve ≥3 months post-implant? → Apixaban acceptable 1, 2, 6
• Native valve disease (AS, AR, MR, mild MS)? → Apixaban preferred over warfarin 4, 8, 5

Step 3: Assess stroke risk and renal function

• Calculate CHA₂DS₂-VASc score (≥2 men, ≥3 women requires anticoagulation) 1
• Check creatinine clearance for dosing adjustments 1

Common Pitfalls to Avoid

• Don't assume "valvular AF" means any valve disease: Only moderate-to-severe mitral stenosis and mechanical valves are true contraindications 1
• Don't use apixaban immediately post-bioprosthetic valve implantation: Wait at least 3 months 2
• Don't apply TAVR data to apixaban use: TAVR patients typically receive dual antiplatelet therapy, not DOACs 2
• Don't forget rheumatic heart disease patients: These patients often have moderate-to-severe mitral stenosis requiring warfarin 3

Dosing Considerations

Standard apixaban dosing is 5 mg twice daily, with dose reduction to 2.5 mg twice daily if patient has ≥2 of: age ≥80 years, weight ≤60 kg, or creatinine ≥1.5 mg/dL. 1, 9