Can valvular heart disease cause pulmonary embolism (PE)?

From the Guidelines

Valvular heart disease can indirectly contribute to pulmonary embolism development, though it is not a direct cause. Certain valvular conditions, particularly those affecting the mitral valve (mitral stenosis) or causing atrial fibrillation, can lead to blood stasis and clot formation in the heart chambers. These clots may then dislodge and travel to the lungs, causing pulmonary embolism. The mechanism involves abnormal blood flow patterns, endothelial damage, and hypercoagulability - components of Virchow's triad that predispose to thrombosis. Patients with valvular heart disease who develop atrial fibrillation are at particularly high risk and often require anticoagulation therapy (such as warfarin with target INR 2-3, or direct oral anticoagulants like apixaban 5mg twice daily) to prevent clot formation, as recommended by the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1. The risk is especially pronounced in mitral stenosis, where the left atrium enlarges and blood flow becomes sluggish, creating ideal conditions for thrombus formation. Patients with mechanical heart valves also require lifelong anticoagulation to prevent thromboembolism, with the choice of anticoagulant depending on the type of valve and patient-specific factors, as outlined in the guidelines 1. Regular echocardiographic monitoring and appropriate anticoagulation management are essential components of care for these patients to prevent pulmonary embolism complications. Key considerations in the management of valvular heart disease to prevent pulmonary embolism include:

• Classification of disease stages based on symptoms, valve anatomy, and ventricular response 1
• Use of noninvasive testing, such as ECG, chest x-ray, and transthoracic echocardiogram, to evaluate patients with valvular heart disease 1
• Consideration of anticoagulation therapy in patients with atrial fibrillation, with the choice of anticoagulant guided by the CHADS-VASc score 1
• Evaluation by a multidisciplinary team for patients with severe valvular heart disease being considered for valve intervention 1.

From the Research

Valvular Heart Disease and Pulmonary Embolism

• Valvular heart disease can increase the risk of pulmonary embolism, as shown in a study published in Circulation 2.
• The study found that left-sided valvular disease was associated with an odds ratio of 13.5 for pulmonary embolism, while right-sided valvular disease had an odds ratio of 74.6.
• Another study published in Chest discussed the use of antithrombotic therapy in valvular heart disease, including the use of oral anticoagulants and antiplatelet agents 3.
• The study recommended long-term oral anticoagulant therapy for patients with rheumatic mitral valve disease and atrial fibrillation, or a history of previous systemic embolism.

Risk of Pulmonary Embolism

• A study published in Cardiovascular & hematological agents in medicinal chemistry found that rheumatic mitral stenosis affects more women and between 40 to 75% of patients may have atrial fibrillation, which increases the risk of stroke and pulmonary embolism 4.
• Another study published in Heart found that patients with aortic stenosis had a higher risk of stroke/systemic embolism, bleeding, and death compared to patients without aortic stenosis 5.
• The study also found that the efficacy and safety benefits of apixaban compared to warfarin were consistent, regardless of the presence of mitral regurgitation, aortic regurgitation, or aortic stenosis.

Management of Valvular Heart Disease and Pulmonary Embolism

• A joint consensus document from the European Heart Rhythm Association and European Society of Cardiology recommended a functional Evaluated Heart valves, Rheumatic or Artificial (EHRA) categorization for the management of patients with atrial fibrillation and valvular heart disease 6.
• The document proposed that the term 'valvular AF' is outdated and recommended the use of EHRA Type 1 and Type 2 VHD categorization to guide the use of oral anticoagulation therapy in patients with atrial fibrillation and valvular heart disease.