How should I approach the management of a patient with mitral stenosis who is also experiencing atrial fibrillation?

Management of a patient with mitral stenosis who is also experiencing atrial fibrillation requires a comprehensive approach focusing on stroke prevention, symptom control, and specialist referral. Stroke prevention is paramount because mitral stenosis with atrial fibrillation significantly increases thromboembolic risk; therefore, anticoagulation is strongly indicated unless contraindicated. Vitamin K antagonists (e.g., warfarin) remain the standard anticoagulant choice in valvular atrial fibrillation, including mitral stenosis, due to the lack of robust evidence supporting direct oral anticoagulants in this setting NICE NG196 Lip et al. 2017.

Rate control is generally the first-line strategy for symptom management in atrial fibrillation associated with mitral stenosis. Beta-blockers are recommended, especially if heart failure is present, to control ventricular rate and improve symptoms NICE NG196,NICE NG208. Digoxin may be considered if beta-blockers or calcium-channel blockers are contraindicated or insufficient, particularly in less active patients NICE NG196.

Rhythm control strategies, including cardioversion, may be considered but require careful assessment. Transoesophageal echocardiography (TOE) is advised before cardioversion to exclude left atrial thrombus, especially in valvular heart disease NICE NG196. Electrical cardioversion is preferred over pharmacological cardioversion for atrial fibrillation persisting longer than 48 hours NICE NG196. Amiodarone may be used to maintain sinus rhythm post-cardioversion, balancing benefits and risks NICE NG196.

Referral to a cardiologist or specialist with expertise in valvular heart disease is essential for patients with moderate to severe mitral stenosis and atrial fibrillation to evaluate the need for interventions such as percutaneous mitral balloon valvotomy or valve surgery NICE NG208. Specialist input is also critical for optimizing anticoagulation management and considering advanced therapies like left atrial appendage occlusion if anticoagulation is contraindicated NICE NG196.

Patient education and shared decision-making are integral, covering stroke risk, anticoagulation benefits and risks, symptom monitoring, and when to seek urgent care NICE NG196. Regular review of anticoagulation efficacy and bleeding risk is necessary, with at least annual monitoring or more frequently if clinical changes occur NICE NG196.