COR LOE Recommendations For patients with AF and native valve heart disease (except rheumatic mitral stenosis [MS]) or who received a bioprosthetic valve >3 months ago, a non vitamin K oral anticoagulant (NOAC) is an effective alternative to VKA anticoagulation and should be administered on the basis of the patient s CHA2 For patients with AF and rheumatic MS, long-term VKA oral anticoagulation is recommended. For patients with new-onset AF 3 months after surgical or transcatheter bioprosthetic valve replacement, anticoagulation with a VKA 3: Harm B-R In patients with mechanical heart valves with or without AF who require long-term anticoagulation with VKA to prevent valve thrombosis, NOACs are not recommended.7 Synopsis Patients with VHD and AF should be evaluated for risk of thromboembolic events and to treat them with oral anticoagulation if they are at high risk. VKAs are the anticoagulation drugs of choice for patients with rheu- matic MS and mechanical heart valves. NOACs are an alternative to VKAs in patients with AF and 1) with CLINICAL STATEMENTS AND GUIDELINES bioprosthetic valves >3 months after implantation or, 2) with native VHD excluding rheumatic MS (Figure 1). Recommendation-Specific Supportive Text comparing NOACs with war- farin included small numbers of patients with VHD, prior valve repair, and bioprosthetic valves (excluding moderate to severe rheumatic MS and mechanical heart valves). In addition to the examinations of insurance claims data and large registries18 have consistently confirmed no signal for a differen- tial effect between NOAC and VKA therapy.19,20 More consistently observed is a net clinical ben- efit, with fewer events in patients using NOACs than in patients on VKA therapy. Validation of the -VASc risk schema in patients with VHD (excluding moderate to severe rheumatic MS and mechanical heart valves) has been performed in confirming the applicability of this score. 