Clinical Review ABC of antithrombotic therapy

Valvar heart disease and prosthetic heart valves

BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7374.1228 (Published 23 November 2002) Cite this as: BMJ 2002;325:1228
  1. Ira Goldsmith,
  2. Alexander G G Turpie,
  3. Gregory Y H Lip

    Thromboembolism and anticoagulant related bleeding are major life threatening complications in patients with valvar heart disease and those with prosthetic heart valves. In these patients effective and safe antithrombotic therapy is indicated to reduce the risks of thromboembolism while keeping bleeding complications to a minimum.


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    Valve thrombosis of a bileaflet prosthetic mitral valve

    Assessment

    Risk factors that increase the incidence of systemic embolism must be considered when defining the need for starting antithrombotic therapy in patients with cardiac valvar disease and prosthetic heart valves. These factors include age, smoking, hypertension, diabetes, hyperlipidaemia, type and severity of valve lesion, presence of atrial fibrillation, heart failure or low cardiac output, size of the left atrium (over 50 mm on echocardiography), previous thromboembolism, and abnormalities of the coagulation system including hepatic failure.

    Secondly, the type, number, and location of prostheses implanted must be considered. For example, mechanical prostheses are more thrombogenic than bioprostheses or homografts, and hence patients with mechanical valves require lifelong anticoagulant therapy. However, the intensity of treatment varies according to the type of mechanical prosthesis implanted. First generation mechanical valves, namely the Starr-Edwards caged ball valve and Bjork-Shiley standard valves, have a high thromboembolic risk; single tilting disc valves have an intermediate thromboembolic risk; and the newer (second and third generation) bileaflet valves have low thromboembolic risks.

    Considerations for antithrombotic therapy in patients with valve disease

    • Assessment of risk for thromboembolic events, which may be patient related or valve prosthesis related

    • Indications for starting treatment

    • Choice of antithrombotic agent

    • Assessment of risk for thromboembolic events, which may be patient related or valve prosthesis related

    • Indications for starting treatment

    • Choice of antithrombotic agent

    • Duration of treatment and optimal therapeutic range

    • Antithrombotic therapy in special circumstances (surgical procedures, pregnancy, and resistance to oral anticoagulants)

    • Management of treatment failures and complications

    In patients with a bioprosthesis in sinus rhythm, antithrombotic therapy with an …

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