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J Thorac Cardiovasc Surg 2009;137:91-93
© 2009 The American Association for Thoracic Surgery

Acquired Cardiovascular Disease

Incidence of thromboembolic complications in patients with mechanical heart valves with a subtherapeutic international normalized ratio

^a Department of Clinical Medicine, University of Insubria, Varese, Italy
^b Thrombosis/Haemostasis and Haematology Unit, University Hospital of Palermo, Palermo, Italy

Received for publication January 21, 2008; revisions received May 25, 2008; accepted for publication July 15, 2008.

^_* Address for reprints: Francesco Dentali, MD, U.O. Medicina I, Ospedale di Circolo, Viale Borri 57, 21100 Varese, Italy. (Email: fdentali{at}libero.it).

Objective: Subtherapeutic international normalized ratios are frequently encountered in clinical practice, and patients with mechanical heart valves with inadequate anticoagulation may be exposed to an increased risk of thromboembolic events. There are no data on thromboembolic event risk for these patients.

Methods: We assessed the current practice patterns in the management of patients with mechanical heart valves with subtherapeutic international normalized ratios and assessed the risk of thromboembolic complications in this setting. The charts of patients with mechanical heart valves followed up in two anticoagulation clinics were reviewed. Patients with a history of stable, therapeutic anticoagulation but with a subtherapeutic international normalized ratio were included. Patients who underwent invasive procedures requiring temporary suspension of antithrombotic therapy were excluded. Data on use and dose of low–molecular weight heparin bridging therapy were collected.

Results: The incidence of objectively confirmed thromboembolic events within 90 days after obtaining the index international normalized ratio was assessed. Two hundred ninety-four patients with mechanical heart valves were included (mean age 63.3 years, 47.3% male). Low–molecular weight heparin was prescribed in 14 cases (4.8%). At 90 days, 1 patient had a thromboembolic complication (0.3%, 95% confidence interval 0%–1.9%).

Conclusion: Patients with previously stable, therapeutic anticoagulation with a subtherapeutic international normalized ratio have a low risk of thromboembolic events. Withholding low–molecular weight heparin bridging therapy is a reasonable therapeutic option in these cases.