In Patients With a Mechanical Valve, Which Agent for Oral Anticoagulation?

A 65-year-old man presents for follow-up to your clinic. He has a history of rate-controlled permanent atrial fibrillation, coronary artery disease s/p CABG, hypertension, diabetes, stroke, and aortic stenosis s/p aortic valve replacement with a mechanical aortic valve. 

Which of the following is/are acceptable oral anticoagulation option(s) for this patient with a CHADS₂ risk score of 4?

A. Vitamin K antagonist (warfarin)
B. Dabigatran
C. Rivaroxaban
D. Apixaban
E. All of the above

Please make a selection, then click here for the answer and discussion.
 

Answer: A. Vitamin K antagonist (warfarin)

Based on the current ACC/AHA guidelines, only warfarin can be used for anticoagulation in individuals with mechanical valves. The RE-ALIGN trial, which was recently published in the NEJM, and terminated early, had a signal for increased bleeding and thromboembolic complications when dabigatran was used (compared with warfarin) in patients with mechanical mitral or aortic valves. Given these findings and the lack of data on other agents, none of the novel oral anticoagulants can be safely used in patients with mechanical valves.

Source: Eikelboom JW, Connollly SJ, Brueckmann M, et al for the RE-ALIGN Investigators. Dabigatran versus warfarin in patients with mechanical heart valves. N Engl J Med. 2013;369:1206-1214.