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- Ira Goldsmith,
- Alexander G G Turpie,
- 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.
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 …
Log in
Log in using your username and password
Log in through your institution
Subscribe from £173 *
Subscribe and get access to all BMJ articles, and much more.
* For online subscription
Access this article for 1 day for:
£38 / $45 / €42 (excludes VAT)
You can download a PDF version for your personal record.