In patients with rheumatic heart disease (RHD) and atrial fibrillation (AF), vitamin K antagonists (VKAs) reduce the rate of cardiovascular events or death compared with rivaroxaban, without increasing the risk of major bleeding. These findings from the INVICTUS trial were presented at ESC.22. In the intention-to-treat analysis, which included 4,531 patients (mean age 50.5 years, 72.3% women) with a median follow-up of 3.1 years, a primary efficacy outcome (a composite of stroke, systemic embolism, myocardial infarction, or death from vascular or unknown causes) occurred in 560 of 2,275 patients receiving rivaroxaban (20 mg once daily) and 446 of 2,256 patients receiving dose-adjusted VKAs. The rivaroxaban group also had a lower restricted mean survival time (1,599 days versus 1,675 days) and a higher incidence of death (restricted mean survival time 1,608 days versus 1,680 days) than the VKA group. No significant differences were found for the primary safety outcome of major bleeding. These results support current guidelines, which recommend the use of VKAs for the prevention of stroke in this patient population.