Anticoagulation Therapy Following Embolic or Hemorrhagic Stroke in the Patient with a Mechanical Heart Valve

Background: An estimated 95,000 heart valve replacements are performed annually in the United States. Prosthetic valves may be either mechanical or bioprosthetic in composition. Mechanical valves offer added durability but commit the patient to taking lifelong anticoagulant therapy. Maintaining therapeutic levels of anticoagulation may be challenging, and inadequate anticoagulation can lead to thromboembolic or hemorrhagic complications. When a patient with a mechanical valve suffers a stroke, management of anticoagulation becomes more controversial and complicated. This article reviews the available evidence and guidelines for management of systemic anticoagulation following stroke in patients with mechanical heart valves. Methods: A review of the PubMed database for pertinent articles, using the keywords “mechanical heart valve”, “anticoagulation”, “cerebrovascular accident”, and “stroke”. The clinical guidelines offered by the American College of Cardiology, American Heart Association, and American Stroke Association were also reviewed. Results: There are no definitive guidelines for the management of patients with mechanical heart valves who suffer a stroke. Most of the data is from small case series and retrospective reviews. Conclusion: Based on the available data, anticoagulation should be resumed rapidly following thromboembolic stroke in patients with a mechanical heart valve, once the risk of hemorrhagic transformation has declined. In the setting of a hemorrhagic stroke, it also appears safe to resume anticoagulation relatively rapidly (after approximately one week), although the risks of further bleeding must be considered. In either case, holding anticoagulation after a stroke for a few days does not expose the patient to significantly increased risk of acute thrombosis.