Cerebral embolism and mitral stenosis: survival with and without anticoagulants

2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease

“…Most trials involved patients who had 1 embolus before the onset of anticoagulation therapy. 421 However, large randomized trials have demonstrated a significant reduction in embolic events by treatment with anticoagulation in subsets of patients with atrial fibrillation not associated with MS. 425,426 In these randomized trials, the subset of patients who benefited most from anticoagulation were those with the highest risk of embolic events. 353,354 Patients with MS at the highest risk for future embolic events are those with prior embolic events and those with paroxysmal or persistent atrial 423,427 Although embolic events are thought to originate from left atrial thrombi, 417,418 the presence or absence of a left atrial thrombus does not appear to correlate with embolic events.…”

“…Patients with either paroxysmal or sustained atrial fibrillation should be treated with long-term anticoagulation with warfarin to prevent embolic events if they do not have a strong contraindication to anticoagulation. 417,421 It is controversial whether percutaneous mitral valvotomy should be performed in patients with new-onset atrial fibrillation and moderate to severe MS who are otherwise asymptomatic.…”

“…368,417,424 An embolic event may thus be the initial manifestation of MS. 367 In patients who have experienced an embolic event, the frequency of recurrence is as high as 15 to 40 events per 100 patient-months. [417][418][419][420][421] There are no randomized trials examining the efficacy of anticoagulation in preventing embolic events specifically in patients with MS. Retrospective studies have shown a 4-to 15-fold decrease in the incidence of embolic events with anticoagulation in these patients. 417,421 This benefit applies to both systemic and pulmonary embolism.…”

“…[417][418][419][420][421] There are no randomized trials examining the efficacy of anticoagulation in preventing embolic events specifically in patients with MS. Retrospective studies have shown a 4-to 15-fold decrease in the incidence of embolic events with anticoagulation in these patients. 417,421 This benefit applies to both systemic and pulmonary embolism. Most trials involved patients who had 1 embolus before the onset of anticoagulation therapy.…”

Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack

“…Although not evaluated in randomized trials, multiple observational studies have reported that long-term anticoagulant therapy effectively reduces the risk of systemic embolism in patients with rheumatic mitral valve disease. [262][263][264][265] Long-term anticoagulant therapy in patients with mitral stenosis who had left atrial thrombus identified by TEE has been shown to result in the disappearance of the left atrial thrombus. 266 The ACC/AHA Task Force on Practice Guidelines has published guidelines for the management of patients with valvular heart disease.…”