Table 5. Target INR for Heart Valve Prostheses

Adapt From ANTITHROMBOTIC AND THROMBOLYTIC THERAPY, 8TH ED: ACCP GUIDELINES : Executive Summary

Jack Hirsh, Gordon Guyatt, Gregory W. Albers, Robert Harrington and Holger J. Schünemann
Chest June 2008 133 : 71S - 109S ; doi:10.1378/chest.08-0693

and ACC/AHA Pocket Guidelines. Management of Patients with Valvular Heart Disease, 2006.

.	INR	DURATION	ALTER NATIVE	ADD
GENERAL APPROACH *	.
Mechanical prostheses(1)	2.0-3.0	Indefinite	.	May add ASA 50-100
Mechanical prostheses, others	2.5-3.5	Indefinite	.	May add ASA 50-100
Mechanical prostheses(3)	2.5-3.5	Indefinite	.	Add ASA 50-100
Mechanical prostheses, with RF(2)	2.5-3.5	Indefinite	.	Add ASA 50-100
.
AORTIC VALVE *	.
AV prostheses, bileaflet (1), no RF(2)	2.0-3.0	Indefinite	.	May add ASA 50-100
AV prostheses, bileaflet (1), with RF(2)	2.5-3-5	Indefinite	.	Add ASA 50-100
AV prostheses, others, no RF(2)	2.5-3.5	Indefinite	.	May add ASA 50-100
AV prostheses, others, with RF(2)	2.5-3.5	Indefinite	.	Add ASA 50-100
.
AV bioprostheses, 1st 3 months	2.5-3.5	3 months	ASA 325	.
-- After 3 months	ASA 80	Indefinite	.	.
-- After 3 months, with RF(2)	2.0-3.0	Indefinite	.	May add ASA 50-100
.
MITRAL VALVE *	.
MV prostheses, mechanical	2.5-3.5	Indefinite	.	May add ASA 50-100
.
MV bioprostheses, 1st 3 months	2.5-3.5	3 months	.	May add ASA 50-100
-- After 3 months	ASA 80	Indefinite	.	May add ASA 50-100
-- After 3 months, with RF(2)	2.5-3.5	Indefinite	.	May add ASA 50-100

For Pacific-Asian (exclude caucasian in this region), The INR range of 2.0-3.0 and 2.5-3.5 may be substituted with INR range of 1.6-2.6 and 2.0-3.0 respectively (Requires more validation)

• * = Warfarin can be started the day after prosthetic valve replacement. UFH or LMWH should be started about 2 days post surgery (when surgical bleeding has been completely controlled) and continue until INR reaches therapeutic level for 2 consecutive days.
• (1) = In aortic position.: St. Jude Medical bileaflet, CarboMedics bileaflet, Medtronic-Hall tilting mono disc, Omnicarbon mono tilting disc, and Sorin bileaflet.
• (2) = Risk factors: History of TIAs, CVA, systemic emboli, severe LV systolic dysfunction, recurrent CHF.
• (3) = Caged ball or caged disk valve
• Adding ASA is not recommended in patient with high risk bleeding.
• ASA dose: ACCP 8th Guidelines = 50-100 mg, ACC/AHA Pocket Guidelines = 75-100 mg