Recommendations on Chronic Use of Antithrombotics for Various Cardiac Conditions
| Condition | Recommendation |
|---|---|
| Nonvalvular atrial fibrillation | Calculate CHADS2a score |
| • CHADS2 score 0 | Aspirin or no antithrombotic |
| • CHADS2 score 1 | Aspirin or OAC |
| • CHADS2 score >1 | OAC |
| Rheumatic mitral valve disease | |
| • With atrial fibrillation, previous embolization, or atrial appendage thrombus, or left atrial diameter >55 mm | OAC |
| • Embolization or appendage clot despite OAC | OAC plus aspirin |
| Mitral valve prolapse | |
| • Asymptomatic | No therapy |
| • With otherwise cryptogenic stroke or TIA | Aspirin |
| • Atrial fibrillation | OAC |
| Mitral annular calcification | |
| • Without atrial fibrillation but systemic embolization, or otherwise cryptogenic stroke or TIA | Aspirin |
| • Recurrent embolization despite aspirin | OAC |
| • With atrial fibrillation | OAC |
| Aortic valve calcification | |
| • Asymptomatic | No therapy |
| • Otherwise cryptogenic stroke or TIA | Aspirin |
| Aortic arch mobile atheroma | |
| • Otherwise cryptogenic stroke or TIA | Aspirin or OAC |
| Patent foramen ovale | |
| • Otherwise cryptogenic ischemic stroke or TIA | Aspirin |
| • Indication for OAC (deep venous thrombosis or hypercoagulable state) | OAC |
| Mechanical heart value | |
| • Aortic position, bileaflet or Medtronic Hall tilting disk with normal left atrial size and sinus rhythm | VKA INR 2.5, range 2-3 |
| • Mitral position tilting disk or bileaflet valve | VKA INR 3.0, range 2.5-3.5 |
| • Mitral or aortic position, anterior-apical myocardial infarct, or left atrial enlargement | VKA INR 3.0, range 2.5-3.5 |
| • Mitral or aortic position, with atrial fibrillation, or hypercoagulable state, or low ejection fraction, or atherosclerotic vascular disease | Aspirin plus VKA INR 3.0, range 2.5-3.5 |
| • Systemic embolization despite target INR | Add aspirin and/or increase INR: prior target was 2.5 increase to 3.0, range 2.5-3.5; prior target was 3.0 increase to 3.5, range 3-4 |
| Bioprosthetic valve | |
| • No other indication for VKA therapy | Aspirin |
| Infective endocarditis | Avoid antithrombotic agents |
| Nonbacterial thrombotic endocarditis | |
| • With systemic embolization | Full-dose unfractionated heparin or SC LMWH |
aCHADS2 score calculated as follows: 1 point for age >75 years, 1 point for hypertension, 1 point for congestive heart failure, 1 point for diabetes, and 2 points for stroke or TIA; sum of points is the total CHADS2 score.
Note: Dose of aspirin is 50-325 mg/d; target INR for OAC is between 2 and 3 unless otherwise specified.
Abbreviations: INR, international normalized ratio; LMWH, low-molecular-weight heparin; OAC, oral anticoagulant (VKA, thrombin inhibitor, oral factor Xa inhibitors); TIA, transient ischemic attack; VKA, vitamin K antagonist.
Sources: Modified from DE Singer et al: Chest 133:546S, 2008; DN Salem et al: Chest 133:593S, 2008.