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International Normalized Ratio (INR) Targets: Valvular Disease
The international normalized ratio (INR) recommendations below are per guidelines from the American College of Chest Physicians (2008).
Rheumatic mitral valve disease
Recommendations for rheumatic mitral valve disease include the following:
INR target (range)
Atrial fibrillation (AF), prior embolism, and/or left atrial thrombus: 2.5 (2.0-3.0)
AF plus systemic embolism or left atrial thrombus : 3.0 (2.5-3.5)
Normal sinus rhythm plus left atrial diameter >55 mm: 2.5 (2.0-3.0)
Preprocedure percutaneous mitral balloon valvotomy (PMBW) with left atrial thrombus : 3.0 (2.5-3.5)
Duration of therapy : Long-term
Mitral valve prolapse
Recommendations for mitral valve prolapse include the following :
INR target (range)
AF, systemic embolism, or recurrent transient ischemic attacks (TIAs): 2.5 (2.0-3.0)
Duration of therapy : Long-term
Mitral annular calcification
Recommendations for mitral annular calcification include the following:
INR target (range)
Recurrent systemic embolism, ischemic stroke, or TIA, without AF : 2.5 (2.0-3.0)
AF : 2.5 (2.0-3.0)
Duration of therapy : long-term
Acute deep venous thrombosis (DVT) of the arm
Recommendations for acute deep venous thrombosis (DVT) of the arm include the following :
INR target (range) : 2.5 (2.0-3.0)
duration of therapy : ≥3 months
Calcific aortic valve disease
Recommendations for calcific aortic valve disease include the following:
INR target (range)
Ischemic stroke : 2.5 (2.0-3.0)
Duration of therapy : Long-term
Patent foramen ovale
Recommendations for patent foramen ovale include the following :
INR target (range)
Cryptogenic ischemic stroke plus risk factors : 2.5 (2.0-3.0)
Duration of therapy : Long-term
Mechanical heart valve
Recommendations for mechanical heart valve include the following :
INR target (range)
Bileaflet mechanical valve in aortic position, sinus rhythm, no left atrial enlargement : 2.5 (2.0-3.0)
Tilting-disk or bileaflet mechanical valve in mitral position : 3.0 (2.5-3.5)
Caged-ball or caged-disk : 3.0 (2.5-3.5)
Risk factors : 3.0 (2.5-3.5)
Systemic embolism despite therapeutic INR : Increase from 2.5 to 3.0 (2.5-3.5) or 3.0 to 3.5 (3.0-4.0)
Aortic position with prosthetic valve thrombus : 3.5 (3.0-4.0)
Mitral position with prosthetic valve thrombus : 4.0 (3.5-4.5)
Duration of therapy : Long-term
Bioprosthetic heart valve
Recommendations for bioprosthetic heart valve include the following :
INR target (range)
Mitral position : 2.5 (2.0-3.0)
History of systemic embolism : 2.5 (2.0-3.0)
Left atrial thrombus : 2.5 (2.0-3.0)
Risk factors : 2.5 (2.0-3.0)
Duration of therapy
Mitral position : 3 months
History of systemic embolism : ≥3 months
Left atrial thrombus : Until documented resolution
Risk factors : Long-term
Risk factors :
AF, anterior-apical ST-segment elevation myocardial infarction, left atrial enlargement, hypercoagulable state, low ejection fraction
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