Last updated March 15, 2022

Antithrombotic And Thrombolytic Therapy For Valvular Disease

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)
(1, B)
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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.
(2, C)
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  • If contraindications to surgery exist, we suggest the use of fibrinolytic therapy.
(2, C)
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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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Recommendation Grading

Overview

Title

Antithrombotic And Thrombolytic Therapy For Valvular Disease

Authoring Organization

Publication Month/Year

February 1, 2012

Document Type

Guideline

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