Subtypes of atrial fibrillation with concomitant valvular heart disease derived from electronic health records: phenotypes, population prevalence, trends and prognosis

Research output: Contribution to journalArticle


  • Amitava Banerjee
  • Victoria Allan
  • Spiros Denaxas
  • Anoop Shah
  • Pier D Lambiase
  • Joseph Jacob
  • Lars H Lund
  • Harry Hemingway

Colleges, School and Institutes

External organisations

  • Institute of Health Informatics, University College London, London, UK.
  • Institute of Cardiovascular Science, Division of Medicine, University College London, London, UK.
  • Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA.
  • Department of Medicine, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.


AIMS: To evaluate population-based electronic health record (EHR) definitions of atrial fibrillation (AF) and valvular heart disease (VHD) subtypes, time trends in prevalence and prognosis.

METHODS AND RESULTS: A total of 76 019 individuals with AF were identified in England in 1998-2010 in the CALIBER resource, linking primary and secondary care EHR. An algorithm was created, implemented, and refined to identify 18 VHD subtypes using 406 diagnosis, procedure, and prescription codes. Cox models were used to investigate associations with a composite endpoint of incident stroke (ischaemic, haemorrhagic, and unspecified), systemic embolism (SSE), and all-cause mortality. Among individuals with AF, the prevalence of AF with concomitant VHD increased from 11.4% (527/4613) in 1998 to 17.6% (7014/39 868) in 2010 and also in individuals aged over 65 years. Those with mechanical valves, mitral stenosis (MS), or aortic stenosis had highest risk of clinical events compared to AF patients with no VHD, in relative [hazard ratio (95% confidence interval): 1.13 (1.02-1.24), 1.20 (1.05-1.36), and 1.27 (1.19-1.37), respectively] and absolute (excess risk: 2.04, 4.20, and 6.37 per 100 person-years, respectively) terms. Of the 95.2% of individuals with indication for warfarin (men and women with CHA2DS2-VASc ≥1 and ≥2, respectively), only 21.8% had a prescription 90 days prior to the study.

CONCLUSION: Prevalence of VHD among individuals with AF increased from 1998 to 2010. Atrial fibrillation associated with aortic stenosis, MS, or mechanical valves (compared to AF without VHD) was associated with an excess absolute risk of stroke, SSE, and mortality, but anticoagulation was underused in the pre-direct oral anticoagulant (DOAC) era, highlighting need for urgent clarity regarding DOACs in AF and concomitant VHD.

Bibliographic note

© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.


Original languageEnglish
Article numbereuz220
Pages (from-to)1176-1184
Number of pages9
Issue number12
Early online date13 Aug 2019
Publication statusPublished - Dec 2019


  • valvular heart disease, atrial fibrillation, electronic health records, stroke, systemic embolism, mortality