SHM Converge Scientific Abstract ePoster Gallery-No Rheum for Failure: New Rheumatic Mitral Stenosis in a Patient With Recurrent Stroke and Atrial Fibrillation on Apixaban

No Rheum for Failure: New Rheumatic Mitral Stenosis in a Patient With Recurrent Stroke and Atrial Fibrillation on Apixaban

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A 67-year-old woman presented with acute left arm weakness and facial droop and was found to have an ischemic stroke from a proximal right M2 occlusion. She had a history of two prior cardioembolic strokes, atrial fibrillation, and was taking apixaban after previously using warfarin. Despite therapeutic apixaban levels and negative testing for thrombophilia or malignancy, she developed another stroke.<br /><br />Further evaluation with transesophageal echocardiography revealed previously unrecognized rheumatic mitral valve disease with mixed moderate mitral stenosis and moderate mitral regurgitation, along with left atrial dilation. This newly identified “valvular AF” explained the apparent failure of DOAC therapy, since warfarin is preferred over direct oral anticoagulants for stroke prevention in atrial fibrillation associated with moderate-to-severe rheumatic mitral stenosis.<br /><br />The case highlights that rheumatic mitral stenosis can be difficult to diagnose because it may present decades after rheumatic fever and may not cause obvious symptoms or a known history of rheumatic disease. In patients with ischemic stroke while on a DOAC, clinicians should assess adherence, drug levels, hypercoagulable states, malignancy, and structural cardiac disease. The report emphasizes that new valvular AF should be considered even in patients with longstanding atrial fibrillation, as recognition changes anticoagulation strategy and can improve secondary stroke prevention.

Asset Subtitle

Jenny Jia Ling Cao

Meta Tag

Author List Ana I. Casanegra, Jenny Jia Ling Cao

Category Clinical Vignettes

Concept Ischemic Stroke

Concept Atrial Fibrillation

Concept Rheumatic Mitral Stenosis

Concept Direct Oral Anticoagulant

Concept Valvular Disease

Distinguished Non-Finalist

Presenter Organization Mayo Clinic Rochester

Presenting Author Jenny Jia Ling Cao

Track Adult

Keywords

ischemic stroke

atrial fibrillation

apixaban failure

rheumatic mitral stenosis

valvular AF

cardioembolic stroke

transesophageal echocardiography

mitral regurgitation

warfarin anticoagulation

secondary stroke prevention

Ischemic Stroke

Atrial Fibrillation

Rheumatic Mitral Stenosis

Direct Oral Anticoagulant

Valvular Disease