@Nabila Laskar Thank you! Warfarin would be first-line here. It is believed to be more effective since it inhibits factor VII, factor IX, factor X, and thrombin. Whereas DOAC’s block individual factors. Since patients with rheumatic mitral valve stenosis and atrial fibrillation are at a very high risk of stroke, a strong anticoagulant whose therapeutic range we can closely monitor, such as warfarin, would be recommended here