Editorial Contributors DW and BS wrote the editorial together. Mitral stenosis and atrial fibrillation Funding The authors have not declared a specific Heart: first published as 10.1136/heartjnl-2019-316282 on 6 February 2020. Downloaded from grant for this research from any funding agency in the Dirk Westermann , Benedikt Schrage public, commercial or not- for- profit sectors. Competing interests None declared. Patient consent for publication Not required. Over the past decades, the incidence of Health Insurance Review and Assessment mitral stenosis (MS) due to rheumatic Service database, which covers 98% of the Provenance and peer review Commissioned; internally peer reviewed. fever has markedly decreased. Regardless, overall South Korean population, Kim et rheumatic fever remains associated with al4 describe a cohort of 42 075 patients about 80% of all cases of MS, and so rela- diagnosed with MS between 2007 and tively the most relevant contributor to 2016. In their study, the authors observed MS.1 Aside from rare causes such as a decreasing incidence of MS during the congenital MS, MS due to myxoma or MS study period, from 10.3 to 3.6 cases per following infiltrating diseases, another 100 000 inhabitants. While this data source Open access This is an open access article distributed in accordance with the Creative Commons Attribution important cause of MS is indeed severe does not allow indepth analysis of patient Non Commercial (CC BY- NC 4.0) license, which permits calcification of the mitral annulus and its data, it is important due to the large popu- others to distribute, remix, adapt, build upon this work leaflets. While this may become more lation it covers and is also used in other non- commercially, and license their derivative works on frequent in the ageing population, it only fields.5 Kim et al show that the prevalence different terms, provided the original work is properly rarely causes severe MS.2 Due to the path- cited, appropriate credit is given, any changes made of atrial fibrillation in patients with MS indicated, and the use is non- commercial. See: http:// omechanism of MS, which includes left was constant over the study period and creativecommons. org/ licenses/ by- nc/ 4. 0/. atrial enlargement due to constant pres- 4 exceeded 60%. The use of anticoagulant © Author(s) (or their employer(s)) 2020. Re- use sure and volume overload, the prevalence therapies in patients with MS increased permitted under CC BY- NC. No commercial re- use. See 1 of atrial fibrillation is high. Oral antico- steadily during the study period, which rights and permissions. Published by BMJ. agulation is recommended not only in reflects the increasing awareness regarding patients with atrial fibrillation, but also in the need for such treatments in patients those with sinus rhythm and dense sponta- with MS with and without atrial fibrillation. To cite Westermann D, Schrage B. Heart Epub ahead neous echocardiographic contrast and/or Importantly, the increasing use of anticoag- 3 of print: [please include Day Month Year]. doi:10.1136/ large left atrium. Unfortunately, only few ulants was not accompanied by a decrease, heartjnl-2019-316282 data are available on the complication but by a plateauing incidence of stroke/ rates of recommended medical systemic embolism in affected patients. treatments. Furthermore, there was also an increase in Importantly, treatment of MS, either by the incidence of intracranial haemorrhage interventional or surgical approaches, is in patients with MS and atrial fibrillation, ► http:// dx. doi. org/ 10. 1136/ heartjnl- 2019- 315883 less supported by evidence- based studies highlighting the need for refined therapies Heart 2020;0:1. compared with other valvular heart doi:10.1136/heartjnl-2019-316282 in this high- risk population. http://heart.bmj.com/ diseases, especially treatment of aortic This paper is of great value as it refo- 3 ORCID iD stenosis. In MS, the interventional therapy cuses attention to valvular atrial fibril- Dirk Westermann http:// orcid. org/ 0000- 0002- 7542- is percutaneous mitral balloon valvotomy lation, MS and their associated risks. 1956 and is reserved for symptomatic patients Additionally, it indicates that the incidence with mainly rheumatic disease, since calci- of MS is higher outside of Europe, with REFERENCES fication might make this approach less a recent Swedish register study reporting 1 Iung B, Leenhardt A, Extramiana F. Management of feasible. Mitral valve surgery is another an incidence rate of about 2 per 100 000 atrial fibrillation in patients with rheumatic mitral stenosis. Heart 2018;104:1062–8. on October 1, 2021 by guest. Protected copyright. option in patients not feasible for this persons between 2003 and 2010.6 Kim interventional treatment or in younger 2 Chandrashekhar Y, Westaby S, Narula J. Mitral stenosis. et al now raise the interesting question The Lancet 2009;374:1271–83. patients with concomitant mitral regurgi- 3 Baumgartner H, Falk V, Bax JJ, et al. ESC/EACTS 3 of whether anticoagulant treatment in tation. Overall, MS is often overlooked, patients with MS should be revised, for guidelines for the management of valvular heart disease. Eur Heart J 2017;2017:2739–91. especially in countries where rheumatic example, introducing novel oral antico- valve disease is less frequent. Therefore 4 Kim JY, Kim S-H, Myong JP, et al. Ten year trends in the agulants (NOACs) as primary anticoag- incidence, treatment and outcomes of patients with new data on the incidence, outcome and ulants over vitamin K antagonists.4 This mitral stenosis in Korea. Heart 2020:[e pub ahead of complication are of importance. statement is based on the finding of the print: 10.1136/heartjnl-2019-315883]. In their Heart paper, Kim et al4 5 Becher PM, Schrage B, Sinning CR, et al. provide plateauing risk of stroke and thrombotic intriguing data on the incidence of MS Venoarterial extracorporeal membrane oxygenation events, as well as the increasing incidence with and without valvular atrial fibrillation for cardiopulmonary support. Circulation of intracerebral bleeding. Ultimately, the 2018;138:2298–300. in South Korea. They describe its associa- available evidence does not provide an 6 Andell P, Li X, Martinsson A, et al. Epidemiology of tion with relevant endpoints. Based on the valvular heart disease in a Swedish nationwide hospital- answer to this question, as patients with based register study. Heart 2017;103:1696–703. MS were excluded from the respective Department of General and Interventional Cardiology, NOAC trials. However, the observed high University Heart Center Hamburg Eppendorf, Hamburg, Germany associated risk in this population and the higher incidence in non- Western coun- Correspondence to Dr Dirk Westermann, Department tries underline the need for randomised of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, 20251 Hamburg, controlled trials of anticoagulant therapy Germany; d. westermann@ uke. de in patients with MS. Westermann D, Schrage B. Heart Month 2020 Vol 0 No 0 1.