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Drug Insight: an overview of current anticoagulation therapy after heart valve replacement

Nature Clinical Practice Cardiovascular Medicine volume 2, pages 415–422 (2005)Cite this article

Abstract

Vitamin K antagonists, such as warfarin, are the gold standard approach for the long-term anticoagulant therapy of patients with mechanical heart valves. Management decisions are, however, based predominantly on expert consensus and on data from nonrandomized, follow-up studies, which have inherent limitations in their methods. Low-intensity anticoagulation therapy provides protection against thromboembolic complications in patients with most types of modern prosthetic heart valve. The addition of low-dose aspirin is safe if international normalized ratio values below 3.5 are maintained. A combined regimen should be considered in high-risk patients and those with coexistent coronary artery or cerebrovascular disease, and in patients who have suffered a thromboembolic event despite a therapeutic international normalized ratio. Thromboprophylaxis with unfractionated or low-molecular-weight heparins is restricted to specific situations, such as when a patient is intolerant to vitamin K antagonists, when surgical procedures require discontinuation of oral anticoagulation, or when the patient is pregnant. A lack of uniformity across practice guidelines make it difficult to reach treatment decisions. Each patient's preference, expressed after counseling about the risks and benefits of each treatment strategy, and an individual assessment of the patient's risk factors, should guide treatment decisions. At present, new anticoagulant agents such as factor Xa inhibitors do not represent a treatment option for heart valve recipients.

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Figure 1: Suggested approach for anticoagulation management of pregnant women with prosthetic cardiac valves.

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Author information

Authors and Affiliations

  1. a Resident, C Piper is a Senior Physician and D Horstkotte is the Head of the Department of Cardiology at the Heart Center North Rhine-Westphalia, Bad Oeynhausen, Germany

    Detlef Hering, Cornelia Piper & Dieter Horstkotte

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  1. Detlef Hering
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  2. Cornelia Piper
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  3. Dieter Horstkotte
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Correspondence to Detlef Hering.

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The authors declare no competing financial interests.

Glossary

INTERNATIONAL NORMALIZED RATIO (INR)

A method that standardizes prothrombin times obtained from reagents of different sensitivities, allowing for comparison between different laboratories

ANTI-XA TEST

Assay used to assess coagulation activity when low-molecular-weight heparins are used, the anticoagulant effect of which is achieved predominantly or exclusively by inhibition of coagulation factor Xa

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Hering, D., Piper, C. & Horstkotte, D. Drug Insight: an overview of current anticoagulation therapy after heart valve replacement. Nat Rev Cardiol 2, 415–422 (2005). https://doi.org/10.1038/ncpcardio0271

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