Antithrombotic And Thrombolytic Therapy For Valvular Disease
Publication Date: February 1, 2012
Last Updated: March 14, 2022
Recommendations
Rheumatic Mitral Valve Disease
In patients with rheumatic mitral valve disease and normal sinus rhythm with a left atrial diameter <55 mm, we suggest not using antiplatelet or VKA therapy. (2, C)
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In patients with rheumatic mitral valve disease and normal sinus rhythm with a left atrial diameter >55 mm, we suggest VKA therapy (target INR, 2.5; range, 2.0-3.0) over no VKA therapy or antiplatelet. (2, C)
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For patients with rheumatic mitral valve disease complicated singly or in combination by the presence of AF or previous systemic embolism, we recommend VKA therapy (target INR, 2.5; range, 2.0-3.0) over no VKA therapy. (1, A)
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For patients with rheumatic mitral valve disease complicated singly or in combination by the presence of left atrial thrombus, we recommend VKA therapy (target INR, 2.5; range, 2.0-3.0) over no VKA therapy. (1, A)
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For patients being considered for percutaneous mitral balloon valvuloplasty (PMBV) with preprocedural TEE showing left atrial thrombus, we recommend postponement of PMBV and that VKA therapy (target INR, 3.0; range, 2.5-3.5) be administered until thrombus resolution is documented by repeat TEE over no VKA therapy. (1, A)
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For patients being considered for PMBV with preprocedural TEE showing left atrial thrombus, if the left atrial thrombus does not resolve with VKA therapy, we recommend that PMBV not be performed. (1, A)
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Aortic Atheroma and Patent Foramen Ovale
In patients with asymptomatic PFO or atrial septal aneurysm, we suggest against antithrombotic therapy. (2, C)
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In patients with cryptogenic stroke and PFO or atrial septal aneurysm, we recommend aspirin (50-100 mg/d) over no aspirin. (1, A)
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In patients with cryptogenic stroke and PFO or atrial septal aneurysm, who experience recurrent events despite aspirin therapy, we suggest treatment with VKA therapy (target INR, 2.5; range, 2.0-3.0) and consideration of device closure over aspirin therapy. (2, C)
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In patients with cryptogenic stroke and PFO, with evidence of DVT,
- we recommend VKA ther apy for 3 months (target INR, 2.5; range, 2.0-3.0)
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and consideration of device closure over no VKA therapy or aspirin therapy. (2, C)
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Endocarditis
In patients with IE, we recommend against routine anticoagulant therapy, unless a separate indication exists. (1, C)
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In patients with IE, we recommend against routine antiplatelet therapy, unless a separate indication exists. (1, B)
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In patients on VKA for a prosthetic valve who develop IE, we suggest VKA be discontinued at the time of initial presentation until it is clear that invasive procedures will not be required and the patient has stabilized without signs of CNS involvement. When the patient is deemed stable without contraindications or neurologic complications, we suggest reinstitution of VKA therapy. (2, C)
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In patients with nonbacterial thrombotic endocarditis (NBTE) and systemic or pulmonary emboli, we suggest treatment with full-dose IV UFH or subcutaneous LMWH over no anticoagulation. (2, C)
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Bioprosthetic Heart Valves
In patients with aortic bioprosthetic valves, who are in sinus rhythm and have no other indication for VKA therapy, we suggest aspirin (50-100 mg/d) over VKA therapy in the first 3 months. (2, C)
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In patients with transcatheter aortic bioprosthetic valves, we suggest aspirin (50-100 mg/d) and clopidogrel (75 mg/d) over VKA therapy and over no antiplatelet therapy in the first 3 months. (2, C)
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In patients with a bioprosthetic valve in the mitral position, we suggest VKA therapy (target INR, 2.5; range, 2.0-3.0) over no VKA therapy for the first 3 months after valve insertion. (2, C)
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In patients with bioprosthetic valves in normal sinus rhythm, we suggest aspirin therapy over no aspirin therapy after 3 months postoperative. (2, C)
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Mechanical Heart Valves
In patients with mechanical heart valves, we suggest bridging with UFH (prophylactic dose) or LMWH (prophylactic or therapeutic dose) over IV therapeutic UFH until stable on VKA therapy. (2, C)
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In patients with mechanical heart valves, we recommend VKA therapy over no VKA therapy for long-term management. (1, B)
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In patients with a mechanical aortic valve, we suggest VKA therapy with a target of 2.5 (range 2.0-3.0) over lower targets. (2, C)
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In patients with a mechanical aortic valve, we recommend VKA therapy with a target of 2.5 (range 2.0-3.0) over higher targets. (1, B)
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In patients with a mechanical mitral valve, we suggest VKA therapy with a target of 3.0 (range 2.5-3.5) over lower INR targets. (2, C)
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In patients with mechanical heart valves in both the aortic and mitral position, we suggest target INR 3.0 (range 2.5-3.5) over target INR 2.5 (range 2.0-3.0). (2, C)
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In patients with a mechanical mitral or aortic valve at low risk of bleeding, we suggest adding over not adding an antiplatelet agent such as low-dose aspirin (50-100 mg/d) to the VKA therapy. (1, B)
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For patients with mechanical aortic or mitral valves we recommend VKA over antiplatelet agents. (1, B)
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Heart Valve Repair
In patients undergoing mitral valve repair with a prosthetic band in normal sinus rhythm, we suggest the use of antiplatelet therapy for the first 3 months over VKA therapy. (2, C)
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In patients undergoing aortic valve repair, we suggest aspirin at 50 to 100 mg/d over VKA therapy. (2, C)
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Prosthetic Valve Thrombosis
For patients with right-sided PVT, in the absence of contraindications we suggest administration of fibrinolytic therapy over surgical intervention. (2, C)
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For patients with left-sided PVT and large thrombus area (≥0.8 cm2)
- we suggest early surgery over fibrinolytic therapy.
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- If contraindications to surgery exist, we suggest the use of fibrinolytic therapy.
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For patients with left-sided PVT and small thrombus area (<0.8 cm2), we suggest administration of fibrinolytic therapy over surgery. For very small, nonobstructive thrombus we suggest IV UFH accompanied by serial Doppler echocardiography to document thrombus resolution or improvement over other alternatives. (2, C)
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Title
Antithrombotic And Thrombolytic Therapy For Valvular Disease
Authoring Organization
American College of Chest Physicians
Publication Month/Year
February 1, 2012
Last Updated Month/Year
May 15, 2023
External Publication Status
Published
Country of Publication
US
Document Objectives
Antithrombotic therapy in valvular disease is important to mitigate thromboembolism, but the hemorrhagic risk imposed must be considered. These antithrombotic guidelines provide recommendations based on the optimal balance of thrombotic and hemorrhagic risk.
Target Patient Population
Patients with thromboembolism associated with valvular heart disease
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Emergency care, Hospital, Operating and recovery room, Outpatient, Radiology services
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Prevention, Management, Treatment
Diseases/Conditions (MeSH)
D000925 - Anticoagulants, D015912 - Thrombolytic Therapy, D000991 - Antithrombins, D006349 - Heart Valve Diseases, D006470 - Hemorrhage
Keywords
anticoagulation, valvular heart disease, Antithrombotic Agents, thrombolytic agents, hemorrhage, Anticoagulation
Methodology
Number of Source Documents
135
Literature Search Start Date
January 1, 2005
Literature Search End Date
October 1, 2009