In: Mechanical Heart23 Sep 2014
Our finding that the risk of TE, but not the risk of bleeding, influenced the aggressiveness of anticoagulant management may be explained by the following considerations. First, physicians may consider the prevention of TE as the primary management objective because the clinical consequence of TE (eg, stroke), resulting from less aggressive anticoagulation therapy, is likely to be greater than that of bleeding (eg, wound hematoma), resulting from aggressive anticoagulation therapy. Second, physicians may be concerned about legal liability if a disabling stroke occurs perioperatively, whereas the occurrence of postoperative bleeding may be more defen-sible. However, there is evidence to suggest that the risk of perioperative TE has been exaggerated, and greater consideration should be given to the risk of postoperative bleeding and its clinical consequences as determinants of anticoagulation preferences. More info
In a cohort study of 45 patients with a mechanical heart valve who underwent elective surgery and received perioperative IV heparin, 13 patients (29%) had postoperative bleeding complications, and in 1 patient (2.2%), the bleeding was fatal. In a meta-analysis of randomized controlled trials involving patients with a mechanical heart valve, in which one patient group did not receive anticoagulant therapy, the risk of TE in patients who were not anticoagulated was 9% per year. If the period in which patients are not fully anticoagulated is limited to 2 or 3 days, as in the perioperative period, the risk for TE during this period would be low (ie, 9% X 3/365 = 0.07%). It is probable that the risk of TE would be higher in a high-risk subgroup (ie, mechanical mitral valve, atrial fibrillation). However, if most physicians are using IV heparin perioperatively, it is possible that this anticoagulation strategy is causing greater morbidity and deaths because of bleeding compared with the morbidity and deaths because of TE if IV heparin had not been used, particularly in patients at lower risk for TE (ie, mechanical aortic valve, sinus rhythm).
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