Clinical Profile of Patients with Atrial Fibrillation According to EHRA (Evaluated Heart Valves, Rheumatic or Artificial) Categorization in A Middle-Income Country


  •   Rose Mary Ferreira Lisboa da Silva

  •   Pedro Antonio Oliveira Aquino Gusmão

  •   Marina de Abreu Arruda

  •   Marcos Antonio Santos Moura

  •   Ananda Queiroz Rocha Lima

  •   Nayara Jassanan Resende dos Santos

  •   Lailla Marilia Santos Mesquita

  •   Óliver Augusto Souza


Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in clinical practice. As of 2017, a functional EHRA (Evaluated Heart valves, Rheumatic or Artificial) categorization was proposed to replace the terms valvular and non-valvular AF. In our country, despite the incidence of rheumatic valve heart disease, studies on this new categorization are scarce Objective: to assess the clinical profile of patients (pts) with AF, using the EHRA categorization as a parameter. Methods: this is a prospective, observational and cross-sectional study with 475 pts with AF from a university institution. Clinical and laboratory evaluations were carried out, as well as the calculation of risk scores for embolism, bleeding and renal function. Statistical analysis was performed by non-parametric tests, in addition to the chi-square test. Results: the pts were divided into 3 groups, according to the EHRA categorization: EHRA 1, with 144 pts, with mitral stenosis or mechanical prosthesis; EHRA 2, with 46 pts with other valvular heart diseases; and EHRA 3, with 285 pts, without valvular heart disease. Mean ages were 51.5; 57.6 and 62.9 years, respectively (p<0.0001). The proportions of women were 75%; 52.1% and 40.7% (p<0.0001). The presentation of the AF was permanent in 68.1%; 60.9%; 52.3% of pts (p=0.008) and 86.0%; 47.8% and 53.3% of pts were using oral anticoagulants, respectively (p<0.0001). The means of left ventricular ejection fraction were 0.58; 0.57 and 0.46; of left atrium were 55.9; 52.5 and 48.1 mm; ATRIA score of 1.4; 1.3 and 2.1; and the glomerular filtration rate of 91.7; 91.1 and 75.0 mL/min/1.73m², respectively (p<0.0001). There was no difference among groups regarding blood pressure and heart rate at study entry and regarding the history of embolism. Conclusions: pts from the EHRA 1 categorization were younger, with a higher proportion of women, permanent AF and use of oral anticoagulants. Systolic dysfunction predominated in those without valve disease, who also had a higher bleeding score and greater impairment of renal function.

Keywords: Anticoagulation, atrial fibrillation, glomerular filtration rate, mechanical prosthetic heart valves, risk assessment, thromboembolism


Lip G, Collet JP, Caterina R, Fauchier L, Lane DA, Larsen TB, et al. Antithrombotic therapy in atrial fibrillation associated with valvular heart disease: a joint consensus document from the European Heart Rhythm Association (EHRA) and European Society of Cardiology Working Group on Thrombosis, endorsed by the ESC Working Group on Valvular Heart Disease, Cardiac Arrhythmia Society of Southern Africa (CASSA), Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), South African Heart (SA Heart) Association and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE). Europace. 2017; 19: 1757-1758.

Coffey S, Roberts-Thomson R, Brown A, Carapetis J, Chen M, Enriquez-Sarano M, et al. Global epidemiology of valvular heart disease. Nat Rev Cardiol. 2021; 18: 853-864.

Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2021: ehab395.

Zühlke L, Karthikeyan G, Engel ME, Rangarajan S, Mackie P, Cupido-Katya Mauff B, et al. Clinical Outcomes in 3343 Children and Adults with Rheumatic Heart Disease From 14 Low- and Middle-Income Countries: Two-Year Follow-Up of the Global Rheumatic Heart Disease Registry (the REMEDY Study). Circulation. 2016; 134: 1456-1466.

Noubiap JJ, Nyaga UF, Ndoadoumgue AL, Nkeck JR, Ngouo A, Bigna JJ. Meta-Analysis of the Incidence, Prevalence, and Correlates of Atrial Fibrillation in Rheumatic Heart Disease. Glob. Heart. 2020; 15: 38.

Antunes MJ. The Global Burden of Rheumatic Heart Disease: Population-Related Differences (It is Not All the Same!). Braz J Cardiovasc Surg. 2020; 35: 958-963.

Andell P, Li X, Martinsson A, Andersson C, Stagmo M, Zöller B, et al. Epidemiology of valvular heart disease in a Swedish nationwide hospital-based register study. Heart. 2017; 103: 1696-1703.

European Society of Cardiology. Section 35 Valvular heart disease. Oxford, UK: Oxford University Press. 2018.

Kumar RK, Antunes MJ, Beaton A, Mirabel M., Nkomo VT, Okello E, et al. Contemporary Diagnosis and Management of Rheumatic Heart Disease: Implications for Closing the Gap: A Scientific Statement From the American Heart Association. Circulation., 2020; 142: e337–e357.

Mulugeta T, Kumela K, Chelkeba L. Clinical, Echocardiographic Characteristics and Management Practices in Patients with Rheumatic Valvular Heart Disease. Open Access Rheumatol. 2020; 12: 233-239.

Staerk L, Sherer JA, Ko D, Benjamin EJ, Helm RH. Atrial Fibrillation: Epidemiology, Pathophysiology, and Clinical Outcomes. Circ Res. 2017; 120: 1501-1517.

Furukawa Y, Miyake M, Fujita T, Koyama T, Takegami M, Kimura T, et al. BPV-AF Registry group. “Rationale, Design, and Baseline Characteristics of the BioProsthetic Valves with Atrial Fibrillation (BPV-AF) Study. Cardiovasc Drugs Ther. 2020; 34: 689-69.

Ariyaratnam JP, Lau DH, Sanders P, Kalman JM. Atrial Fibrillation and Heart Failure: Epidemiology, Pathophysiology, Prognosis, and Management. Card Electrophysiol Clin. 2021; 13: 47-62.

January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland J. C Jr, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation. 2019; 140: e125-e151.

Steffel J, Collins R, Antz M, Cornu P, Desteghe L, Haeusler KG, et al. 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation. Europace. 2021; 23(10): 1612-1676.

Wendelboe AM, Raskob GE. Global Burden of Thrombosis: Epidemiologic Aspects. Circ Res. 2016; 118: 1340-7.

Lip G.Y.H, Jensen M, Melgaard L, Skjøth F, Nielsen PB, Larsen TB. Stroke and bleeding risk scores in patients with atrial fibrillation and valvular heart disease: evaluating 'valvular heart disease' in a nationwide cohort study. Europace. 2019; 21: 33-40.

Melgaard L, Jensen M, Overvad TF, Larsen TB, Lip GYH, et al. Thromboembolic and bleeding outcomes in patients with atrial fibrillation and valvular heart disease: A descriptive nationwide cohort study. Int J Clin Pract. 2020; 74, e13589.

Santos IS, Goulart AC, Olmos RD, Thomas GN, Lip GYH, Lotufo PA, et al. Atrial fibrillation in low- and middle-income countries: a narrative review. Eur Heart J Suppl. 2020; 22: O61-O77.

Rashid S, Tysarowski M, Naranjo J, Dhole A, Petrovic L, Aziz EF. Characteristics of warfarin under-prescription in older adults with atrial fibrillation. Int J Cardiol Heart Vasc. 2021; 37: 100914.

Rossini R, Casula M, Ferlini M. Atrial fibrillation in advanced renal failure: are there alternative solutions to warfarin-dicumarol?. Eur Heart J Suppl. 2021; 23: E138-E141.

Kapłon-Cieślicka A, Budnik M, Gawałko M, Peller M, Gorczyca I, Michalska A, et al. Atrial fibrillation type and renal dysfunction as important predictors of left atrial thrombus. Heart. 2019; 105: 1310-1315.

Michalska A, Gorczyca I, Chrapek M, Kapłon-Cieślicka A, Uziębło-Życzkowska B, Starzyk K, et al. Does the CHA2DS2-VASc scale sufficiently predict the risk of left atrial appendage thrombus in patients with diagnosed atrial fibrillation treated with non-vitamin K oral anticoagulants?. Medicine (Baltimore). 2020; 99: e20570.

Márquez MF, Baños-González MA, Guevara-Valdivia ME, Vázquez-Acosta J, de Los Ríos Ibarra MO, Aguilar-Linares JA, et al. Anticoagulation Therapy by Age and Embolic Risk for Nonvalvular Atrial Fibrillation in Mexico, an Upper-Middle-Income Country: The CARMEN-AF Registry. Glob Heart. 2020; 15: 32.

Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, et al. Heart Disease and Stroke Statistics-2021 Update: A Report from the American Heart Association. Circulation. 2021; 143: e254-e743.

Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, et al. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J. 2021; 42: 3427-3520.


How to Cite
Lisboa da Silva, R. M. F., Gusmão, P. A. O. A., Arruda, M. de A., Moura, M. A. S., Lima, A. Q. R., dos Santos, N. J. R., Mesquita, L. M. S., & Souza, Óliver A. (2022). Clinical Profile of Patients with Atrial Fibrillation According to EHRA (Evaluated Heart Valves, Rheumatic or Artificial) Categorization in A Middle-Income Country. European Journal of Clinical Medicine, 3(1), 26–30.