Non vitamin K oral anticoagulation has not been studied in patients with rheumatic MS, and these patients were excluded from the randomized AF trials. In addition to the much higher risk of embo- lization with rheumatic valve disease as compared with other causes of valve disease, there is con- cern that rheumatic disease also affects the atrial muscle, resulting in an increased risk of blood flow stasis and thrombosis in the body of the LA, as well as the LA appendage.1 Further studies are required to confirm these findings.2 2. Patients with rheumatic MS are prone to develop- ing atrial arrhythmias specifically AF. Significant detrimental hemodynamic consequences may be associated with the acute development of AF, pri- marily from the rapid ventricular response, which shortens the diastolic filling period and increases The treatment of acute AF consists of anticoagulation and control of the heart rate response with negative dromotropic agents. If the rate cannot be adequately controlled with medica- tions, cardioversion may be necessary to improve hemodynamics. In the stable patient, the decision CLINICAL STATEMENTS AND GUIDELINES for rate control versus rhythm control is dependent on multiple factors, including the duration of AF, hemodynamic response to AF, LA size, prior epi- sodes of AF, and history of embolic events. It is more difficult to achieve rhythm control in patients with rheumatic MS because the rheumatic process itself may lead to progressive fibrosis and enlargement of the atria, fibrosis of the internodal and interatrial tracts, and damage to the sinoatrial node. 3. The use of negative dromotropic agents for the treatment of symptoms in patients with rheumatic MS in normal sinus rhythm has been controversial. 