Question-272

A 50 year old male developed mitral valve vegetation and regurgitation during an episode of infective endocarditis. He underwent mitral valve replacement with a prosthetic valve. He is previously known to have AF.

What will you give?


a) Asprin
b) Warfarin
c) Aspirin and Clopidogrel
d) Aspirin and Warfarin

Mechanical valves require anticoagulation with warfarin, but the intensity varies, depending on the location and type of valve. Mechanical mitral valves require an INR of 2.5 to 3.5, whereas bileaflet mechanical valves in the aortic position require an INR of 2.0 to 3.0.

Aspirin is recommended for all patients with prosthetic valves—mechanical or bioprosthetic

D?

b?

A

Recommendations for the management of patients after heart valve surgery
i.Antithrombotic management should encompass the effective management of risk factors for thrombo-embolism (TE) in addition to the prescription of antithrombotic drugs.9,10

ii.Until new direct antithrombin drugs are licensed for patients following valve surgery, vitamin K antagonist drugs will be required for oral anticoagulation.11

iii.Oral anticoagulation is recommended for the following situations.

a.Lifelong for all patients with mechanical valves irrespective of valve type or date of introduction.12

b.Lifelong for patients with bioprostheses or mitral repair who have other indications for anticoagulation, e.g. atrial fibrillation (AF), heart failure, and impaired LV function (ejection fraction <30%).12

c.For the first 3 months, in all patients with bioprostheses or mitral valve repair involving the use of a prosthetic annuloplasty ring. Although there is widespread use of aspirin as an alternative to anticoagulation for the first 3 months in patients with no other indications for anticoagulation, there are no randomized studies to support the safety of this strategy.13,14

iv.Patients with bioprostheses or mitral valve repair who are not on anticoagulation require close follow-up not only to detect evidence of structural degeneration or recurrence of mitral regurgitation, but also to detect the onset of AF.15

http://eurheartj.oxfordjournals.org/content/26/22/2463.full
iv.Prevention of further TE events involves:

a.Treatment or reversal of remediable risk factors such as AF, hypertension, hypercholesterolaemia, diabetes, smoking, chronic infection, and prothrombotic blood test abnormalities.b.Optimization of anticoagulation control, if possible with patient self-management, on the basis that better control is more effective than simply increasing the target INR.c.Because of the increased risk of bleeding, antiplatelet drugs should not be prescribed ‘automatically’ in all cases, but rather targeted to specific situations in which there is likely to be a benefit, e.g. in arterial disease. If aspirin is used, it should be prescribed in a low-dose formulation (≤100 mg daily) and combined with low-intensity anticoagulation (INR ≤2.5–3.5 depending on the site of the prosthesis and its thrombogenicity).

The correct answer is d