Valvular Heart Disease Overview

Patients with valvular heart disease (VHD) needing oral anticoagulation (OAC) therapy with vitamin K antagonists (VKAs), specifically those with mechanical prosthetic heart valves or moderate-to-severe mitral stenosis.

Patients with VHD needing OAC, which can be either VKA or direct oral anticoagulants (DOACs), encompassing all other native valve conditions, mitral valve repair, bioprosthetic valve replacements, and transcatheter aortic valve interventions (TAVIs).

DOACs are a suitable alternative to vitamin K antagonists (VKAs) at least three months post-implantation of a bioprosthetic heart valve, for patients with atrial fibrillation (AF).

Patients with rheumatic mitral stenosis should not receive DOACs as anticoagulation.

The need for anticoagulation in atrial fibrillation (AF) is determined by the CHADS₂VASc score.

An artificial heart valve requiring anticoagulation to prevent blood clots.

A narrowing of the mitral valve, a heart valve, making blood flow difficult.

Anticoagulant medications that directly inhibit blood clotting factors, as an alternative to vitamin K antagonists.

Warfarin is used to treat or prevent blood clots (thrombosis) when risk factors are present.

A previous blood clot that traveled to another part of the body.

A condition where the blood is prone to forming clots.

An irregular heartbeat that increases risk of stroke.

A blood clot in the left upper chamber of the heart.

An enlarged left atrium, a risk factor for stroke.

Direct Oral Anticoagulants used to prevent blood clots.

Patients with AF and Mitral Stenosis taking Warfarin experienced a higher risk of intracranial bleeding compared to patients using DOACs.

Rivaroxaban use as an alternative to Warfarin shows no difference in major bleeding risk, but a lower risk of stroke and death.

A clinical trial studying rivaroxaban vs. warfarin in AF and RHD, showing lower bleeding incidence with rivaroxaban.

A blood clot that travels from the heart to another part of the body, causing blockage and damage. It can be a stroke (CVA) or a systemic embolic event.

If a patient with a mechanical aortic valve experiences a TE event while their INR is within the therapeutic range, the INR goal should be increased to 3.0 (2.5-3.5) or low-dose aspirin added.

If a patient with a mechanical mitral valve experiences a TE event while their INR is within the therapeutic range, the INR goal should be increased to 4.0 (3.5-4.0) or low-dose aspirin added.

For left-sided mechanical valves (mitral or aortic), urgent evaluation and emergency surgery or fibrinolytic infusion is recommended in the presence of symptoms. For right-sided valves, IV heparin or VKA (if no contraindication to OAC) is indicated.

Fibrinolytic infusion is an acceptable alternative to surgery for patients with high surgical risk, small thrombus burden, mild heart failure, and low bleeding risk.

Warfarin (INR goal 2.5) for at least 3 months and sometimes up to 6 months if low bleed risk. Alternatively, ASA 75-100 mg daily is used if high bleed risk.

Warfarin (INR goal 3.0) for life if risk factors for thromboembolic complications. A bridge therapy may be required. Concomitant ASA 75-81 mg daily is common.

Contraindicated for mechanical valve replacement. Other direct oral anticoagulants (DOACs) aren't recommended.

Warfarin (INR goal 2.5) for at least 3 months, up to 6 months if low bleed risk; or ASA 75-100 mg daily if high bleed risk

Warfarin (INR goal 3) for life, with a bridge, if necessary.

Atrial fibrillation (AF), hypercoagulable state, left ventricular (LV) dysfunction, and previous thromboembolism. Severity of LV dysfunction amplifies risk.

History of gastrointestinal bleeding (GIB), high response to ASA, poorly controlled high blood pressure (HTN), advanced age, multiple medications, and frequent antibiotics.

1.5-2 is an acceptable range for patients without thromboembolism risk factors after the initial 3 months on anticoagulation

Warfarin along with daily ASA.

The target international normalized ratio (INR) for warfarin is 2.5 for prosthetic or biological heart valves, but it may vary depending on the patient’s individual needs and factors.

Conditions where thrombolytic therapy is absolutely not recommended, such as prior intracranial hemorrhage, or malignant intracranial neoplasm

Conditions where thrombolytic therapy is less ideal, and should be used with caution, such as poorly controlled high blood pressure or recent surgery

Initial phase of alteplase administration, involves a 25 mg IV dose over 25 hours.

Second phase of thrombolytic treatment, involves a 6-hour infusion of UFH (Heparin).

Determining the effectiveness of thrombolytic therapy, typically using Transesophageal Echocardiography (TEE)

International Normalized Ratio, a measure of how quickly blood clots, used for Warfarin therapy.

Activated Partial Thromboplastin Time, a measure of how quickly blood clots; used for Heparin therapy.

Vitamin K Antagonist therapy, such as Warfarin.

The necessity of carefully evaluating the current treatment regimen, for patients with valve thrombosis.

Specific target ranges for the INR (International Normalized Ratio) used for monitoring Warfarin treatment.

Standardized approaches to managing medical conditions, developed by professionals based on evidence and consensus.

They ensure patients receive evidence-based care, optimizing treatment outcomes and minimizing variability in care.

Unwanted or harmful effects that occur as a result of a medication or treatment.

Regular follow-up appointments allow for checking for reported adverse effects and assessing overall well-being.

Recognizing signs and symptoms of side effects early allows for prompt intervention and adjustments to treatment.

Reporting observed side effects to the prescribing physician is essential for timely intervention and patient safety.

Documenting changes in symptoms, lab results, or vital signs helps healthcare teams make informed decisions about treatment.

Based on observed effects, treatments can be continued, adjusted, or discontinued.

Following treatment guidelines and monitoring for side effects is crucial for patient safety.

Documentation enables the healthcare team to make informed decisions about continuing, adjusting, or discontinuing a medication by keeping track of changes in symptoms, lab results, or vital signs.

Thorough gathering of information about a patient's health, including medical history, allergies, pre-existing conditions, recent surgeries, and current health status.

When two or more medications are taken together and their effects on the body are altered, potentially leading to increased toxicity or decreased efficacy.

Determining the correct amount of medication for a patient based on their weight, age, kidney function, and other factors.

Regularly checking for any negative effects of a medication on a patient's body.

Patient assessment is crucial for identifying individual needs and choosing the most effective treatment plan, taking into account factors like medical history, allergies, and lifestyle.

Interactions can lead to increased toxicity, decreased efficacy, and even life-threatening complications.

Accurate dosage calculation is crucial for optimal treatment outcomes, ensuring efficient drug delivery and achieving the desired results.

Continuous monitoring helps to identify and manage any potential side effects from medication, ensuring patient safety and well-being.

Factors like patient weight, age, kidney function, and specific medication effects all play a role in determining the appropriate dosage.

By carefully reviewing medication history, identifying potential drug interactions or contraindications, and choosing appropriate medications, healthcare professionals can minimize adverse effects and ensure patient safety.