Skip to Main Content

++

The worldwide burden of valvular heart disease (VHD) continues to grow due to increases in life expectancy combined with the high incidence of rheumatic heart disease in developing nations.1 Patients with VHD and certain comorbid conditions or prosthetic heart valves (PHVs) are at high risk for thromboembolic complications and often require antithrombotic therapy (Table 81–1). Although bleeding is a risk with all antithrombotic agents, the frequency and consequences of a stroke make drug therapy appropriate in many patients with VHD.2,3

++
Table Graphic Jump Location
Table 81–1. Valve Disease and Antithrombotic Therapy
++

Antithrombotic therapy among individuals with native valve disease, defined by the authors as VHD in the absence of PHV or mitral stenosis, is based on the presence of concomitant risk factors (Fig. 81–1). The most common risk factors include atrial fibrillation and left ventricular systolic dysfunction.

++
Figure 81–1.
Graphic Jump Location

Risk of thromboembolism. Clinical variables define valve disease patients as being at high or low risk of thromboembolic events. LV, left ventricle.

++

Atrial Fibrillation

++

Multiple randomized controlled trials have demonstrated the clinical benefits of antithrombotic therapy with either warfarin or aspirin compared with placebo or no treatment in reducing ischemic events among individuals with "nonvalvular" atrial fibrillation.4,5 Based on a meta-analysis of >28,000 patients comprising 29 trials, adjusted-dose warfarin therapy was associated with a 60% and 40% reduction in ischemic stroke compared with placebo and antiplatelet therapy, respectively.5 A recently completed trial found that the addition of clopidogrel to aspirin also reduced ischemic events, including stroke, among patients with atrial fibrillation who were unsuitable for vitamin K antagonist therapy.6 The benefits of anticoagulation are graded, increasing as the risk for ischemic stroke increases. Multiple risk stratification schemes exist for guiding clinicians in assessing stroke risk among individuals with nonvalvular atrial fibrillation.7-10 In summary, warfarin is recommended in any atrial fibrillation patient who has had a systemic embolus. It is also recommended in those with two or more of the following: diabetes mellitus, a history of hypertension, coronary artery disease, congestive heart failure, and age >75 years. Those with none or only one risk factor can reasonably be given aspirin 325 mg/d as an alternative.11

++

Left Ventricular Dysfunction

++

Among clinically stable individuals with left ventricular dysfunction, the ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessCardiology Full Site: One-Year Subscription

Connect to the full suite of AccessCardiology content and resources including textbooks such as Hurst's the Heart and Cardiology Clinical Questions, a unique library of multimedia, including heart imaging, an integrated drug database, and more.

$595 USD
Buy Now

Pay Per View: Timed Access to all of AccessCardiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.