Can patients with infectious endocarditis be safely anticoagulated?

Mandeep Singh Randhawa; James Pile; Marcelo Gomes

doi:10.3949/ccjm.83a.15027

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TABLE 1

Guidelines for managing anticoagulation in patients with infective endocarditis

American Heart Association¹

Discontinuing all forms of anticoagulation in patients with mechanical valve infectious endocarditis who have experienced a central nervous system embolic event for at least 2 weeks is reasonable.

Initiating aspirin or other antiplatelet agents as adjunctive therapy in infective endocarditis is not recommended.

Continuing long-term antiplatelet therapy at the time of development of infective endocarditis with no bleeding complications may be considered.

European Society of Cardiology²

Interruption of antiplatelet and anticoagulant therapy is recommended in the presence of intracranial hemorrhage or other major bleeding.

In ischemic stroke without hemorrhage, replacement of oral anticoagulant (anti-vitamin K) therapy by unfractionated or low- molecular-weight heparin for 1–2 weeks should be considered under close monitoring.

In patients with intracranial hemorrhage and a mechanical valve, unfractionated or low-molecular-weight heparin should be reinitiated as soon as possible following multidisciplinary discussion.

In the absence of stroke, replacement of oral anticoagulant therapy by unfractionated or low-molecular-weight heparin for 1–2 weeks should be considered in the case of Staphylococcus aureus infectious endocarditis under close monitoring.

Thrombolytic therapy is not recommended in patients with infectious endocarditis.

American College of Chest Physicians³

In patients with infectious endocarditis, routine anticoagulant and antiplatelet therapy is not recommended unless a separate indication exists.

In patients with a prosthetic valve who are on anticoagulation and who develop infectious endocarditis, it is suggested to discontinue the anticoagulation at the time of initial presentation until it is clear that invasive procedures will not be required and the patient has stabilized without signs of central nervous system involvement. When the patient is deemed stable without contraindications or neurologic complications, reinstitution of anticoagulant therapy is suggested.