Antithrombotic and Thrombolytic Therapy for Valvular Disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

doi:10.1378/chest.11-2305

Chest

Volume 141, Issue 2, Supplement, February 2012, Pages e576S-e600S

https://doi.org/10.1378/chest.11-2305 Get rights and content

Background

Antithrombotic therapy in valvular disease is important to mitigate thromboembolism, but the hemorrhagic risk imposed must be considered.

Methods

The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement.

Results

In rheumatic mitral disease, we recommend vitamin K antagonist (VKA) therapy when the left atrial diameter is > 55 mm (Grade 2C) or when complicated by left atrial thrombus (Grade 1A). In candidates for percutaneous mitral valvotomy with left atrial thrombus, we recommend VKA therapy until thrombus resolution, and we recommend abandoning valvotomy if the thrombus fails to resolve (Grade 1A). In patients with patent foramen ovale (PFO) and stroke or transient ischemic attack, we recommend initial aspirin therapy (Grade 1B) and suggest substitution of VKA if recurrence (Grade 2C). In patients with cryptogenic stroke and DVT and a PFO, we recommend VKA therapy for 3 months (Grade 1B) and consideration of PFO closure (Grade 2C). We recommend against the use of anticoagulant (Grade 1C) and antiplatelet therapy (Grade 1B) for native valve endocarditis. We suggest holding VKA therapy until the patient is stabilized without neurologic complications for infective endocarditis of a prosthetic valve (Grade 2C). In the first 3 months after bioprosthetic valve implantation, we recommend aspirin for aortic valves (Grade 2C), the addition of clopidogrel to aspirin if the aortic valve is transcatheter (Grade 2C), and VKA therapy with a target international normalized ratio (INR) of 2.5 for mitral valves (Grade 2C). After 3 months, we suggest aspirin therapy (Grade 2C). We recommend early bridging of mechanical valve patients to VKA therapy with unfractionated heparin (DVT dosing) or low-molecular-weight heparin (Grade 2C). We recommend long-term VKA therapy for all mechanical valves (Grade 1B): target INR 2.5 for aortic (Grade 1B) and 3.0 for mitral or double valve (Grade 2C). In patients with mechanical valves at low bleeding risk, we suggest the addition of low-dose aspirin (50-100 mg/d) (Grade 1B). In valve repair patients, we suggest aspirin therapy (Grade 2C). In patients with thrombosed prosthetic valve, we recommend fibrinolysis for right-sided valves and left-sided valves with thrombus area < 0.8 cm² (Grade 2C). For patients with left-sided prosthetic valve thrombosis and thrombus area ≥ 0.8 cm², we recommend early surgery (Grade 2C).

Conclusions

These antithrombotic guidelines provide recommendations based on the optimal balance of thrombotic and hemorrhagic risk.

Section snippets

Summary of Recommendations

Note on Shaded Text: Throughout this guideline, shading is used within the summary of recommendations sections to indicate recommendations that are newly added or have been changed since the publication of Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence- Based Clinical Practice Guidelines (8th Edition). Recommendations that remain unchanged are not shaded.

2.0.1. In patients with rheumatic mitral valve disease and normal sinus rhythm with a left atrial

Methods

The development of the current recommendations followed the general approach of Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.³ In brief, literature searches to update the existing database from the AT8 guidelines were performed (January 1, 2005 to October 2009). The literature was rated according to

Rheumatic Mitral Valve Disease

Rheumatic mitral valve disease carries the greatest risk of systemic thromboembolism of any common form of acquired valvular disease. Wood⁵ cited a prevalence of systemic emboli of 9% to 14% in several large early series of patients with mitral stenosis. In 1961, Ellis and Harken⁶ reported that 27% of 1,500 patients undergoing surgical mitral valvotomy had a history of clinically detectable systemic emboli. Among 754 patients followed up for 5,833 patient-years, Szekely⁷ observed an incidence

Mitral Valve Prolapse and Mitral Valve Strands

Mitral valve prolapse (MVP) is a common congenital form of valve disease. Although early evidence from case series and control studies suggested an association with stroke,34, 35, 36, 37, 38, 39, 40 Gilon et al⁴¹ and the Framingham Heart Study⁴² failed to replicate the results. More recently, Avierinos et al⁴³ found that people with MVP had an excess lifetime risk of stroke or transient ischemic attack (TIA) (RR, 2.2; P < .001). Thus, it is as yet unclear whether MVP truly increased the risk of

Mitral Annular Calcification

Mitral annular calcification (MAC), like MVP, may be a source of cardioembolic stroke. The best estimate of the embolic potential of MAC comes from the Framingham Heart Study.⁴⁶ Among 1,159 individuals with no history of stroke at the index echocardiographic examination, the risk of stroke in those with MAC was 2.1 times greater than those without MAC (5.1% without MAC vs 13.8% with MAC, P = .006), independent of traditional risk factors for stroke. There was a continuous relationship between

Calcified Aortic Valve

Clinically significant systemic emboli in isolated aortic valve disease are uncommon. A lack of association between aortic valve calcification and clinical emboli has been supported by several studies.49, 50, 51 Thus, in the absence of other indications, antithrombotic therapy does not have a role in calcified aortic valve disease.

Atherosclerotic Plaque of the Proximal Aorta

The presence of aortic plaque is associated with stroke risk.52, 53 In a TEE substudy of the Stroke Prevention in Atrial Fibrillation (SPAF) trial, the risk of stroke at 1 year in patients with AF with complex aortic plaque was 12% to 20% vs 1.2% if no plaque was observed.⁵⁴ Cohen et al⁵⁵ demonstrated that aortic plaques > 4 mm in thickness increased the risk of vascular events, and this risk was further increased by lack of plaque calcification (RR = 10.3; 95% CI, 4.2-25.2). There are no

Native Valve Endocarditis: Role of Anticoagulants and Antiplatelet Agents

Native valve infective endocarditis (IE) is a serious infectious entity, the morbidity of which is primarily related to the consequences of systemic embolism from valve vegetations. The risk of embolization is proportional to the size of the vegetation and the type of organism (eg, Staphylococcus aureus increases risk).67, 68 The majority of clinically apparent emboli from left-sided lesions involve the CNS resulting in catastrophic stroke. The incidence of pulmonary emboli in right-sided

Early Postoperative Bridging to Intermediate/Long-term Therapy (Postoperative Day 0 to 5)

There are no studies examining early bridging therapy such as UFH or LMWH prior to antiplatelet therapy or VKA initiation in the bioprosthetic valve population. Therefore, we are currently unable to make recommendations on this topic.

Antithrombotic Therapy in the First 3 Months After Surgery

The first 3 months after valve implantation are a high-risk period for thromboembolic events, particularly in the mitral valve population.93, 94 Because the risk of a thromboembolic event varies by valve location, we have generated separate evidence profiles by

Early Postoperative Bridging to Intermediate/Long-term Therapy (Postoperative Day 0 to 5)

The options for antithrombotic therapy immediately after mechanical heart valve replacement include oral VKA therapy with or without initial bridging using UFH or LMWH. We identified no randomized trials comparing these strategies.

Antithrombotic Therapy After Mitral Valve Repair

Mitral valve repair commonly involves the removal of redundant or pathologic leaflet tissue, the placement of a synthetic ring or band to decrease annular size, and perhaps the resuspension of leaflets with new or transposed chordate. We have identified no randomized trial evaluating the use of antithrombotic therapy after mitral valve repair. Aramendi et al¹⁰⁶ published a prospective cohort study examining the outcomes of 235 mitral repair or replacement patients. The data suggest superiority

Prosthetic Valve Thrombosis

Prosthetic valve obstruction may be the result of thrombosis, pannus ingrowth, or both.¹³⁰ Clinical history and echocardiographic study are used to determine the cause. This is important, since thrombolysis will not be effective in pannus ingrowth.

Prosthetic valve thrombosis has an incidence ranging from 0.1% to 5.7% per patient-year. Although rare, this complication is potentially lethal. Treatment of this pathology consists of surgery, thrombolytic therapy, or anticoagulation. The choice of

Acknowledgments

Author Contributions: As Topic Editor, Dr Whitlock oversaw the development of this article, including the data analysis and subsequent development of the recommendations contained herein.

Dr Whitlock: contributed as the Topic Editor.

Dr Sun: contributed as a panelist.

Dr Fremes: contributed as a panelist.

Dr Rubens: contributed as a panelist.

Dr Teoh: contributed as a panelist.

Financial/nonfinancial disclosures: The authors of this guideline provided detailed conflict of interest information related

References (135)

JJ You et al.
Antithrombotic therapy for atrial fibrillation: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines
Chest
(2012)
A Holbrook et al.
Evidence-based management of anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines
Chest
(2012)
GH Guyatt et al.
Methodology for the development of antithrombotic therapy and prevention of thrombosis guidelines: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines
Chest
(2012)
S MacLean et al.
Patient values and preferences in decision making for antithrombotic therapy: a systematic review: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines
Chest
(2012)
LB Ellis et al.
Arterial embolization in relation to mitral valvuloplasty
Am Heart J
(1961)
R Daley et al.
Systemic arterial embolism in rheumatic heart disease
Am Heart J
(1951)
HA Fleming
Anticoagulants in rheumatic heart-disease
Lancet
(1971)
C Vigna et al.
Left atrial thrombus and spontaneous echo-contrast in nonanticoagulated mitral stenosis. A transesophageal echocardiographic study
Chest
(1993)
KC Goswami et al.
Clinical and echocardiographic predictors of left atrial clot and spontaneous echo contrast in patients with severe rheumatic mitral stenosis: a prospective study in 200 patients by transesophageal echocardiography
Int J Cardiol
(2000)
MC Chen et al.
Mechanism of reducing platelet activity by percutaneous transluminal mitral valvuloplasty in patients with rheumatic mitral stenosis
Chest
(2004)

S Silaruks et al.

A prognostic model for predicting the disappearance of left atrial thrombi among candidates for percutaneous transvenous mitral commissurotomy

J Am Coll Cardiol

(2002)

D Roy et al.

Usefulness of anticoagulant therapy in the prevention of embolic complications of atrial fibrillation

Am Heart J

(1986)

DH Kang et al.

Comparison of outcomes of percutaneous mitral valvuloplasty versus mitral valve replacement after resolution of left atrial appendage thrombi by warfarin therapy

Am J Cardiol

(1998)

MG Lansberg et al.

Antithrombotic and thrombolytic therapy for ischemic stroke: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines

Chest

(2012)

PK Fulkerson et al.

Calcification of the mitral annulus: etiology, clinical associations, complications and therapy

Am J Med

(1979)

PF Nestico et al.

Mitral annular calcification: clinical, pathophysiology, and echocardiographic review

Am Heart J

(1984)

E Ferrari et al.

Atherosclerosis of the thoracic aorta and aortic debris as a marker of poor prognosis: benefit of oral anticoagulants

J Am Coll Cardiol

(1999)

PA Tunick et al.

Effect of treatment on the incidence of stroke and other emboli in 519 patients with severe thoracic aortic plaque

Am J Cardiol

(2002)

PA Tunick et al.

Atheromas of the thoracic aorta: clinical and therapeutic update

J Am Coll Cardiol

(2000)

B Schneider et al.

Improved morphologic characterization of atrial septal aneurysm by transesophageal echocardiography: relation to cerebrovascular events

J Am Coll Cardiol

(1990)

S Homma et al.

Atrial anatomy in non-cardioembolic stroke patients: effect of medical therapy

J Am Coll Cardiol

(2003)

I Meissner et al.

Patent foramen ovale: innocent or guilty? Evidence from a prospective population-based study

J Am Coll Cardiol

(2006)

GW Petty et al.

Population-based study of the relationship between patent foramen ovale and cerebrovascular ischemic events

Mayo Clin Proc

(2006)

G Di Salvo et al.

Echocardiography predicts embolic events in infective endocarditis

J Am Coll Cardiol

(2001)

I Vilacosta et al.

Risk of embolization after institution of antibiotic therapy for infective endocarditis

J Am Coll Cardiol

(2002)

H Masur et al.

Prosthetic valve endocarditis

J Thorac Cardiovasc Surg

(1980)

KL Chan et al.

A randomized trial of aspirin on the risk of embolic events in patients with infective endocarditis

J Am Coll Cardiol

(2003)

PC Block et al.

Prosthetic valve endocarditis

J Thorac Cardiovasc Surg

(1970)

JA Lopez et al.

Nonbacterial thrombotic endocarditis: a review

Am Heart J

(1987)

LR Rogers et al.

Cerebral infarction from non-bacterial thrombotic endocarditis. Clinical and pathological study including the effects of anticoagulation

Am J Med

(1987)

M Heras et al.

High risk of thromboemboli early after bioprosthetic cardiac valve replacement

J Am Coll Cardiol

(1995)

MI Ionescu et al.

Clinical durability of the pericardial xenograft valve: ten years experience with mitral replacement

Ann Thorac Surg

(1982)

P Wood

Diseases of the Heart and Circulation

(1956)

P Szekely

Systemic embolization and anticoagulant prophylaxis in rheumatic heart disease

BMJ

(1964)

PB Deverall et al.

Incidence of systemic embolism before and after mitral valvotomy

Thorax

(1968)

K Cassella et al.

Patients with mitral stenosis and systemic emboli

Arch Intern Med

(1964)

HA Dewar et al.

A study of embolism in mitral valve disease and atrial fibrillation

Br Heart J

(1983)

WE Hay et al.

Age and atrial fibrillation as independent factors in auricular mural thrombus formation

Am Heart J

(1942)

N Coulshed et al.

Systemic embolism in mitral valve disease

Br Heart J

(1970)

RR Kasliwal et al.

A study of spontaneous echo contrast in patients with rheumatic mitral stenosis and normal sinus rhythm: an Indian perspective

Br Heart J

(1995)

Predictors of thromboembolism in atrial fibrillation: II. Echocardiographic features of patients at risk. The Stroke Prevention in Atrial Fibrillation Investigators

Ann Intern Med

(1992)

LR Caplan et al.

Atrial size, atrial fibrillation, and stroke

Ann Neurol

(1986)

F Mounier-Vehier et al.

Silent infarcts in patients with ischemic stroke are related to age and size of the left atrium

Stroke

(1993)

Echocardiographic predictors of stroke in patients with atrial fibrillation: a prospective study of 1066 patients from 3 clinical trials

Arch Intern Med

(1998)

CW Chiang et al.

Predictors of systemic embolism in patients with mitral stenosis. A prospective study

Ann Intern Med

(1998)

HJ Levine

Which atrial fibrillation patients should be on chronic anticoagulation?

J Cardiovasc Med

(1981)

CK Friedberg

Diseases of the Heart

(1966)

AB Carter

Prognosis of cerebral embolism

Lancet

(1965)

BA Carabello

Modern management of mitral stenosis

Circulation

(2005)

GF Adams et al.

Cerebral embolism and mitral stenosis: survival with and without anticoagulants

J Neurol Neurosurg Psychiatry

(1974)

Cited by (541)

Complications in transcatheter aortic valve replacement: A comprehensive analysis and management strategies
2024, Current Problems in Cardiology
Transcatheter Aortic Valve Replacement (TAVR) marks a significant advancement in treating aortic stenosis (AS), especially for patients with high surgical risks. This concise review outlines TAVR's development, its broader application to include lower-risk patients, and innovations in the device and procedural technology. Clinical trials, notably the PARTNER series, affirm TAVR's efficacy, showing it matches or surpasses surgical aortic valve replacement (SAVR) in mortality reduction, hemodynamic benefits, and symptom alleviation, including heart failure. However, TAVR entails complications such as paravalvular leakage (PVL), conduction disorders, and increased cerebrovascular event risks. We evaluate these issues, their prevalence, causative factors, and clinical consequences, emphasizing improvements in valve design and technique that have significantly lowered PVL rates. The role of aortic valve anatomy and calcification in PVL and conduction issues is analyzed, underlining the necessity for meticulous patient selection and procedural planning. Further, the review delves into cerebrovascular event risks, their origins, and preventative strategies, including cerebral protection devices and the judicious use of anticoagulant and antiplatelet therapies. TAVR presents a less invasive, promising alternative to SAVR, but requires careful complication management to optimize patient results. Ongoing innovation and research are vital for advancing TAVR's techniques, improving valve designs, and extending its reach, thereby enhancing AS patients' quality of life.
Anticoagulation for mechanical aortic valves: An international survey of current practice patterns and perceptions
2024, Thrombosis Update
For patients with mechanical aortic valves, guideline recommended INR targets range from 2.0 to 3.5, depending on thromboembolic risk factors. Supporting data is largely historical and of low quality. We aimed to characterize clinicians’ practices around INR targets for these patients and perceptions of evidence supporting these recommendations.
A 33-question web-based survey was sent to 75 cardiologists, cardiac surgeons, and thrombosis specialists globally. We inquired about anticoagulation practices for patients with mechanical aortic valves, perceptions of guideline recommendations, and interest in participating in a randomized controlled trial comparing lower and higher INR targets in these patients.
Of 55 respondents (73% response rate), 78% worked in academic hospitals. In patients with mechanical aortic valve and no additional thromboembolic risk factors, 80% targeted an INR of 2.5. Among patients with additional thromboembolic risk factors, 48% targeted an INR of 2.5, while 44% targeted an INR of 3.0. Additionally, 57% of respondents believed that evidence for the guidelines was up to date, and 53% believed that it applied to bi-leaflet valves.
However, 57% of respondents said that the evidence was not high quality. Lastly, 66% of respondents would accept a higher thromboembolic risk to reduce risk of major bleeding; 86% were willing to randomize patients with mechanical aortic valve to a target INR of 2.0 if they had no thromboembolic risk factors.
Clinicians target different INRs for patients with mechanical aortic valves; their perception of the evidence and guidelines varies. Of respondents, 86% would randomize patients to lower INR targets.
Marantic Endocarditis With Recurrent Thromboembolism Potentially Associated With COVID-19 and Delayed Onset of Malignancy
2024, CJC Open
Thromboembolic events are frequently found in patients with COVID-19 due to the underlying hypercoagulable and inflammatory states. However, very few cases of marantic endocarditis were reported. Herein, we present a rare case of marantic endocarditis with recurrent thromboembolic events in a woman with COVID-19 infection and for whom an intestinal tumor was found 18 months later. She suffered from cardiogenic shock following two embolic inferior ST-elevation myocardial infarction (STEMI) and also developed right femoral artery thrombosis and two catheter-related venous thrombosis. Marantic endocarditis are typically seen with advanced malignancy, but ensuring a thorough medical follow-up can help detect insidious or delayed onset malignancy.
Management of anticoagulation in patients with infective endocarditis
2023, Thrombosis Research
Infective endocarditis (IE) carries a high risk of vascular complications (e.g., cerebral embolism, intracerebral hemorrhage, and renal infarction), which are correlated with increased early and late mortality. Although anticoagulation is the cornerstone for management of thromboembolic complications, it remains controversial and challenging in patients with IE. An appropriate anticoagulation strategy is crucial to improving outcomes and requires a good understanding of the indication, timing, and regimen of anticoagulation in the setting of IE. Observational studies have shown that anticoagulant treatment failed to reduce the risk of ischemic stroke in patents with IE, supporting that IE alone is not an indication for anticoagulation. In the absence of randomized controlled trials and high-quality meta-analyses, however, current guidelines on IE were based largely on observational data and expert opinion, providing few specific recommendations on anticoagulation. A multidisciplinary approach and patient engagement are required to determine the timing and regimen of anticoagulation in patients with IE, especially in specific situations (e.g., receiving warfarin anticoagulation at the time of IE diagnosis, cerebral embolism or ischemic stroke, intracerebral hemorrhage, or urgent surgery). Collectively, individualized strategies on anticoagulation management of IE should be based on clinical evaluation, available evidence, and patient engagement, and ultimately be developed by the multidisciplinary team.
Low-Dose vs Standard Warfarin After Mechanical Mitral Valve Replacement: A Randomized Trial
2023, Annals of Thoracic Surgery
Current guidelines recommend a target international normalized ratio (INR) range of 2.5 to 3.5 in patients with a mechanical mitral prosthesis. The Prospective Randomized On-X Anticoagulation Clinical Trial (PROACT) Mitral randomized controlled noninferiority trial assessed safety and efficacy of warfarin at doses lower than currently recommended in patients with an On-X (Artivion, Inc) mechanical mitral valve.
After On-X mechanical mitral valve replacement, followed by at least 3 months of standard anticoagulation, 401 patients at 44 North American centers were randomized to low-dose warfarin (target INR, 2.0-2.5) or standard-dose warfarin (target INR, 2.5-3.5). All patients were prescribed aspirin, 81 mg daily, and encouraged to use home INR testing. The primary end point was the sum of the linearized rates of thromboembolism, valve thrombosis, and bleeding events. The design was based on an expected 7.3% event rate and 1.5% noninferiority margin.
Mean patient follow-up was 4.1 years. Mean INR was 2.47 and 2.92 (P <.001) in the low-dose and standard-dose warfarin groups, respectively. Primary end point rates were 11.9% per patient-year in the low-dose group and 12.0% per patient-year in the standard-dose group (difference, −0.07%; 95% CI, −3.40% to 3.26%). The CI >1.5%, thus noninferiority was not achieved. Rates (percentage per patient-year) of the individual components of the primary end point were 2.3% vs 2.5% for thromboembolism, 0.5% vs 0.5% for valve thrombosis, and 9.13% vs 9.04% for bleeding.
Compared with standard-dose warfarin, low-dose warfarin did not achieve noninferiority for the composite primary end point. (PROACT Clinicaltrials.gov number, NCT00291525).
Risk of Stroke and Major Bleeding With Vitamin K Antagonist Use After Mitral Valve Repair
2023, Annals of Thoracic Surgery
Guidelines are discordant on the use of a vitamin K antagonist (VKA) after mitral valve repair (MVr) to reduce the risk of cerebral embolic events. We performed an observational study among patients who underwent a MVr, without perioperative atrial fibrillation, to determine the risk of cerebral ischemic and major bleeding events with or without VKA.
From 2004 to 2016, we included patients who underwent MVr, using a national administrative claims database. Those with preoperative atrial fibrillation and anticoagulant use were excluded. Patients were stratified based on the presence of a VKA. Inverse probability weighting with a Cox proportional hazard model was used.
After MVr, 754 patients were discharged on VKA and 1462 on no-VKA. We found no difference in the cumulative incidence for embolic stroke at 180 days (VKA: 2.21% vs no-VKA: 1.50%; hazard ratio, 1.35; P = .38). However, VKA patients had a significantly increased risk for any-cause major bleeding events at 180 days (VKA: 8.58% vs no-VKA: 4.21%; hazard ratio, 2.09; P < .001). VKA patients also had increased need for a pericardiocentesis/pericardial window at 30 days after discharge (VKA: 1.13% vs no-VKA: 0.37%; hazard ratio, 3.88; P = .025).
Our study suggests that VKA after MVr does not reduce the risk of cerebral embolic events but is associated with an increased risk of major bleeding events.

View all citing articles on Scopus

Funding/Support: The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines received support from the National Heart, Lung, and Blood Institute [R13 HL104758] and Bayer Schering Pharma AG. Support in the form of educational grants was also provided by Bristol-Myers Squibb; Pfizer, Inc; Canyon Pharmaceuticals; and sanofi-aventis US.

Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://chestjournal.chestpubs.org/content/141/2_suppl/1S.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

View full text

Chest

Background

Methods

Results

Conclusions

Section snippets

Summary of Recommendations

Methods

Rheumatic Mitral Valve Disease

Mitral Valve Prolapse and Mitral Valve Strands

Mitral Annular Calcification

Calcified Aortic Valve

Atherosclerotic Plaque of the Proximal Aorta

Native Valve Endocarditis: Role of Anticoagulants and Antiplatelet Agents

Early Postoperative Bridging to Intermediate/Long-term Therapy (Postoperative Day 0 to 5)

Antithrombotic Therapy in the First 3 Months After Surgery

Early Postoperative Bridging to Intermediate/Long-term Therapy (Postoperative Day 0 to 5)

Antithrombotic Therapy After Mitral Valve Repair

Prosthetic Valve Thrombosis

Acknowledgments

Chest

Chest

Chest

Chest

Am Heart J

Am Heart J

Lancet

Chest

Int J Cardiol

Chest

J Am Coll Cardiol

Am Heart J

Am J Cardiol

Chest

Am J Med

Am Heart J

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Mayo Clin Proc

J Am Coll Cardiol

J Am Coll Cardiol

J Thorac Cardiovasc Surg

J Am Coll Cardiol

J Thorac Cardiovasc Surg

Am Heart J

Am J Med

J Am Coll Cardiol

Ann Thorac Surg

Diseases of the Heart and Circulation

Systemic embolization and anticoagulant prophylaxis in rheumatic heart disease

BMJ

Incidence of systemic embolism before and after mitral valvotomy

Thorax

Patients with mitral stenosis and systemic emboli

Arch Intern Med

A study of embolism in mitral valve disease and atrial fibrillation

Br Heart J

Age and atrial fibrillation as independent factors in auricular mural thrombus formation

Am Heart J

Systemic embolism in mitral valve disease

Br Heart J

A study of spontaneous echo contrast in patients with rheumatic mitral stenosis and normal sinus rhythm: an Indian perspective

Br Heart J

Predictors of thromboembolism in atrial fibrillation: II. Echocardiographic features of patients at risk. The Stroke Prevention in Atrial Fibrillation Investigators

Ann Intern Med

Atrial size, atrial fibrillation, and stroke

Ann Neurol

Silent infarcts in patients with ischemic stroke are related to age and size of the left atrium

Stroke

Echocardiographic predictors of stroke in patients with atrial fibrillation: a prospective study of 1066 patients from 3 clinical trials

Arch Intern Med

Predictors of systemic embolism in patients with mitral stenosis. A prospective study

Ann Intern Med

Which atrial fibrillation patients should be on chronic anticoagulation?

J Cardiovasc Med

Diseases of the Heart