I have a 65-year-old female with metallic aortic valve on warfarin, presented with dense left sided hemiplegia. Brain CT showed massive right hemisphere infarction. The patient admitted to the ward as a stroke attributed to valvular lesion. The cardiologist strongly recommends continuing warfarin to prevent further thromboembolic showering and to prevent valve dysfunction, while the neurologist strongly recommends holding warfarin as the risk of intra-infarct bleeding is high. In view of these two contradictory opinions, how would I manage this case? I need experts’ opinion
I would consider the following elements: type of mechanic valve, function of mechanic valve , INR at time of stroke and the weeks before.
Continuing full anti coagulation too early after stroke may be dangerous in this case. I would use LMWH at intermediate dose (70U/kg bid) looking at clinical status and cerebral imaging in the following days reducing the dose if bleeding inside the cerebral ischemia does occur. I would also use elastic stockings for Vte prevention.
I agree with Dr. Pengo, but I prefer Heparin IV 1ml 4/4 h after correction of the INR. If there is intra-infarct bleeding, I think the control of Heparin more easy than LMWH. This is a vere desagreeable condition for cardiologist and neurologist and very dangerous for patients.
Dear all, why don't we stop anticoagulation for a couple of days untill the risk of intra-infarct bleeding become low, meanwhile we should monitor valve function by daily echocardiography.
Often cerebral bleeding in these patints is secobdary to a n ischemic event with superimosed blreeding because of anticoagulant treatment.
1) Make of AoVP. With 2nd (SJM, Carbomedix) and 3rd (ATS, On-X) generation models one can feel relatively secure withholding anticoagulants for a while in the aortic position.
2) Status of pat. If she's recovering from her stroke, I would be tempted to rest her a while before embarking on a regular anticoagulation regime.
3) Heparin. As José and Vittorio state, you could refer to a 1 mg/kg b.i.d./ t.i.d./q.i.d. as required, which will let you buy precious time and, if necessary, may be neutralised rapidly.
We conducted a multidisciplinary meeting involving the neurologist and the cardiologist with us as general medicine team, after long discussion we agreed to stop warfarin for 2 weeks and to commence enoxaparin in prophylactic dose with aspirin; meanwhile the cardiologist did echocardiography daily to follow the metallic valve status. Unfortunately, the patient developed cardiac arrest on the third day and died despite full resuscitation. We don’t know exactly the cause for her death as autopsy was not performed.
Dear Fahmi, thank you for sharing this unlucky case. Ill-fated cases are seldom reported in the literature. However, strokes in patients with prosthetic heart valves and/or atrial fibrillation despite adequate anticoagulation are not rare in my experience, so they are undoubtedly worth of discussion. I would add some personal thoughts to this discussion. 1) If this case would have been included in a clinical trial, I would probably adjudicate the death to heart valve thrombosis. Sudden death is not the usual clinical presentation of ischemic stroke superimposed bleeding. 2) A two weeks period of warfarin suspension is reasonable when facing a very large brain infarction, but this seems to me a too long time for a patient with a mechanical valve. 3) To my knowledge the only result one can expect from a prophylactic dose of LMWH is the prevention of deep vein thrombosis. 4) In my country, no LMWH is licensed for use in atrial fibrillation or in patients with mechanical heart valves, at any dosage. This is a very relevant legal pitfall. I would therefore have preferred standard heparin in continuos infusion, with close neurologic monitoring, resuming warfarin as soon as possible under clinical judgement. I agree with José, since unfractionated heparin is easily stopped if the neurological state deteriorates. 5) You've certainly done the right thing in daily monitoring with echocardiography. I agree also with aspirin.