What is the best option to decrease the risk of stroke in a patient with severe Rheumatic (rheumatoid) mitral regurgitation and Atrial Fibrillation (A fib)?

Warfarin is the Definitive Answer for Stroke Prevention in Rheumatic Mitral Regurgitation with Atrial Fibrillation

Warfarin with a target INR of 2.0-3.0 is the only appropriate anticoagulant for this patient, as DOACs including apixaban are contraindicated in rheumatic valvular heart disease. 1

Why Warfarin is Correct (Option A)

• The American Heart Association explicitly recommends warfarin as the definitive treatment to reduce stroke risk in patients with severe rheumatic mitral regurgitation and atrial fibrillation, maintaining an INR of 2.0-3.0 1

• The American College of Cardiology states that DOACs should not be used in patients with rheumatic valvular heart disease, as all major DOAC trials specifically excluded these patients 1

• Rheumatic mitral regurgitation—even without stenosis—represents rheumatic valvular disease and requires warfarin therapy 1

• Patients with rheumatic mitral valve disease and AF face up to a 17-fold increased stroke risk compared to non-valvular AF, making appropriate anticoagulation critical 1

• Warfarin reduces stroke risk by 60-68% in AF patients overall 1

Why the Other Options are Wrong

Aspirin (Option B) - Grossly Inadequate

• Aspirin alone provides grossly inadequate protection and should not be relied upon in this high-risk population 1

• A comparative study in rheumatic mitral stenosis with AF showed three nonfatal cardioembolic strokes in the aspirin group versus zero in the warfarin group over three years 2

• The study explicitly concluded that aspirin should not be used for primary prevention of cardiac embolism in chronic rheumatic heart disease 2

Apixaban (Option C) - Contraindicated

• The American College of Cardiology explicitly states that DOACs, including apixaban, should not be used in patients with moderate-to-severe mitral stenosis or rheumatic valvular heart disease 1

• There is no safety or efficacy data for DOACs in rheumatic valvular disease, as these patients were systematically excluded from all major DOAC trials 1

• Even if the patient has difficulty maintaining therapeutic INR with warfarin, switching to a DOAC is not appropriate due to lack of evidence 1

Digoxin (Option D) - Not for Stroke Prevention

• Digoxin is a rate-control agent that does not provide anticoagulation or stroke prevention 3

• While digoxin may be used for heart rate control in AF with MR, it has no role in thromboembolic prophylaxis 3

Practical Implementation of Warfarin Therapy

• Target INR: 2.0-3.0 1

• Monitor INR at least weekly during initiation, then monthly when stable 1

• Indefinite anticoagulation is required as long as AF persists and rheumatic valvular disease remains 1

Critical Pitfalls to Avoid

• Never use a DOAC in rheumatic valvular disease, even if INR control is difficult 1

• Do not add aspirin to warfarin routinely, as this increases bleeding risk without additional stroke prevention benefit in most AF patients 1

• Do not discontinue anticoagulation after successful rhythm control, as stroke risk persists 1

• Ensure the patient understands this is lifelong therapy requiring regular monitoring 1