Antithrombotic Therapy in Valvular Heart Disease—Native and Prosthetic

Salem, Deeb N.; Stein, Paul D.; Al‐Ahmad, Amin; Bussey, Henry I.; Horstkotte, Dieter; Miller, Nancy H.; Pauker, Stephen G.

doi:10.1378/chest.126.3_suppl.457s

Cited by 327 publications

(104 citation statements)

References 191 publications

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“…However, the issue of the use of LMWHs in patients with mechanical heart valves remains unresolved. Although some experts point out that LMWHs provide adequate protection in nonpregnant patients with mechanical heart valve prostheses, 25,26 recent guidelines raise concern about their use in this setting and recommend the use of unfractionated heparin in the 48 hours preceding the procedure while the INR is Ͻ2. 27,28 The adherence to the protocol was overall fairly consistent throughout the study.…”

Section: Discussionmentioning

confidence: 99%

Standardized Low–Molecular-Weight Heparin Bridging Regimen in Outpatients on Oral Anticoagulants Undergoing Invasive Procedure or Surgery

Cucchini²,

et al. 2009

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Background-Bridging therapy with low-molecular-weight heparin is usually recommended in patients who must stop oral anticoagulants before surgical or invasive procedures. To date, there is no universally accepted bridging regimen tailored to the patient's thromboembolic risk. This prospective inception cohort management study was designed to assess the efficacy and safety of an individualized bridging protocol applied to outpatients. Methods and Results-Oral anticoagulants were stopped 5 days before the procedure. Low-molecular-weight heparin was started 3 to 4 days before surgery and continued for 6 days after surgery at 70 anti-factor Xa U/kg twice daily in high-thromboembolic-risk patients and prophylactic once-daily doses in moderate-to low-risk patients. Oral anticoagulation was resumed the day after the procedure with a boost dose of 50% for 2 days and maintenance doses afterward. The patients were followed up for 30 days. Of the 1262 patients included in the study (only 15% had mechanical valves), 295 (23.4%) were high-thromboembolic-risk patients and 967 (76.6%) were moderate-to low-risk patients. In the intention-to-treat analysis, there were 5 thromboembolic events (0.4%; 95% confidence interval, 0.1 to 0.9), all in high-thromboembolic-risk patients. There were 15 major (1.2%; 95% confidence interval, 0.7 to 2.0) and 53 minor (4.2%; 95% confidence interval, 3.2 to 5.5) bleeding episodes. Major bleeding was associated with twice-daily low-molecular-weight heparin administration (high-risk patients) but not with the bleeding risk of the procedure. Conclusions-This management bridging protocol, tailored to patients' thromboembolic risk, appears to be feasible, effective, and safe for many patients, but safety in patients with mechanical prosthetic valves has not been conclusively established.

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Section: Discussionmentioning

confidence: 99%

Standardized Low–Molecular-Weight Heparin Bridging Regimen in Outpatients on Oral Anticoagulants Undergoing Invasive Procedure or Surgery

Cucchini²,

et al. 2009

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“…Patients with prosthetic mitral valves were excluded because of their particularly high risk of thromboembolic events and higher target international normalized ratio (INR) levels. 19 …”

Section: Cohort Identificationmentioning

confidence: 99%

Racial/Ethnic Differences in Ischemic Stroke Rates and the Efficacy of Warfarin Among Patients With Atrial Fibrillation

Shen

Yao

Brar

et al. 2008

Stroke

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Background and Purpose-Warfarin reduces stroke risk in studies of predominantly white patients with atrial fibrillation (AF). Whether nonwhites also have lower rates of stroke while treated with warfarin is unclear. Methods-A multiethnic stroke-free cohort hospitalized with nonrheumatic AF was identified in a large health maintenance organization. Stroke risk factors (advanced age, diabetes, hypertension, and heart failure), warfarin use, and anticoagulation intensity were assessed. Crude ischemic stroke rates were calculated by Poisson regression for each group while using and not using warfarin. Cox proportional hazard models were constructed to assess the independent effect of race/ethnicity on ischemic stroke. Results-Between 1995 and 2000, we identified 18 867 AF hospitalizations (78.5% white, 8% black, 9.5% Hispanic, and 3.9% Asian). Over the course of 63 204 person-years follow-up (median, 3.3 years), 1226 ischemic strokes were identified. The percent-time on warfarin did not differ by race/ethnicity. The median percent-time on warfarin that international normalized ratio was 2 to 3 was 54.5% overall, but it was lower in blacks at 47.8%, whereas the other groups had a rate of Ϸ54%. The rate ratios (95% CI) of ischemic stroke with warfarin compared to without warfarin for whites, blacks, Hispanics, and Asians were 0.

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“…of Chest Physicians endorses LMWH administration (with the same low grade of recommendation as for UH) as a possible strategy until the international normalized ration (INR) is stable at therapeutic levels, 11 but, the American Heart Association/American College of Cardiology does not compel to use any heparin 12 : "It is important to note that thromboembolic risk is increased early after insertion of the prosthetic valve. The use of heparin early after prosthetic valve replacement before warfarin achieves therapeutic levels is controversial.…”

mentioning

confidence: 99%

Low-Molecular-Weight Heparin as a Bridging Anticoagulant Early After Mechanical Heart Valve Replacement

et al. 2006

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Background-After mechanical heart valve replacement (MHVR), long-term use of unfractionated heparin is sometimes required because vitamin K antagonists (VKA) are temporarily contraindicated or because the time to reach the target international normalized ratio is long. The aim of this study was to investigate the feasibility of low-molecular-weight heparin treatment in these patients. Methods and Results-This work was conducted as a prospective study. We selected all patients (nϭ695) who underwent MHVR and were transferred to a postoperative cardiac rehabilitation center between January 2000 and January 2005. The study focused on patients who had not yet started VKA therapy or who had a below-target international normalized ratio despite VKA therapy. Unfractionated heparin was replaced by enoxaparin (100 IU/kg BID) until VKA treatment was fully effective. Two hundred fifty patients (60Ϯ11 years old) were enrolled 16Ϯ11 days after surgery (aortic valve replacement, nϭ190; mitral valve replacement, nϭ34; double valve replacement, nϭ26). Of these, 50% had permanent or transient atrial fibrillation, 40% had hypertension, 13% had diabetes, and 19% had a history of cardiac surgery. The mean duration of low-molecular-weight heparin treatment was 8.3Ϯ6.0 days. Patients were followed for 90 days, during which there were two major and three minor bleeding episodes and one transient ischemic attack. There were no cases of valve thrombosis and no deaths. Conclusions-After MHVR, one third of patients leave the cardiac surgery unit before VKA treatment is fully effective.Bridging anticoagulation therapy with enoxaparin appears to be feasible during this high-risk period for thromboembolism and could shorten the length of hospital stay. (Circulation. 2006;113:564-569.)

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Antithrombotic Therapy in Valvular Heart Disease—Native and Prosthetic

Cited by 327 publications

References 191 publications

Standardized Low–Molecular-Weight Heparin Bridging Regimen in Outpatients on Oral Anticoagulants Undergoing Invasive Procedure or Surgery

Standardized Low–Molecular-Weight Heparin Bridging Regimen in Outpatients on Oral Anticoagulants Undergoing Invasive Procedure or Surgery

Racial/Ethnic Differences in Ischemic Stroke Rates and the Efficacy of Warfarin Among Patients With Atrial Fibrillation

Low-Molecular-Weight Heparin as a Bridging Anticoagulant Early After Mechanical Heart Valve Replacement

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