Thromboembolic risk stratification and bridging considerations
| Indication . | Mechanical heart valve . | Atrial fibrillation . | VTE . | ||||
|---|---|---|---|---|---|---|---|
| Guideline(s) . | ACCP 2012, ACC/AHA 2020 . | ACCP 2012, ACC 2017 . | ACCP 2012, ASH 2018 . | ||||
| Thrombotic risk . | Criteria . | Recommendation . | Criteria* . | Recommendation . | Criteria . | Recommendation . | |
| High | • All mitral valve • Caged-ball and tilting disc • Stroke or TIA in past 6 months | Suggest bridging/reasonable to bridge | CHADS2 >4 | CHA2DS2-VASc >7 | Suggest bridging | • Within 3 months • Severe thrombophilia | CHEST 2012: Suggest bridging ASH 2018: Not addressed |
| Moderate | Bileaflet aortic valve + risk factors • Atrial fibrillation • Prior stroke or TIA • Hypertension • Diabetes • Congestive heart failure • Age >75 years | Individualized decision based on patient and procedural nuances | CHADS2 3-4 | CHA2DS2-VASc 5 or 6 | Individualized decision based on patient and procedural nuances | • Past 3-12 months • Recurrent VTE • Active cancer • Nonsevere thrombophilia | CHEST 2012: Individualized decision based on patient and procedural nuances ASH 2018: Do not bridge |
| Low | Bileaflet aortic valve without risk factors | Do not bridge | CHADS2 ≤2 | CHA2DS2-VASc <4 | Do not bridge | More than 12 months ago | CHEST 2012: Do not bridge ASH 2018: Do not bridge |
| Indication . | Mechanical heart valve . | Atrial fibrillation . | VTE . | ||||
|---|---|---|---|---|---|---|---|
| Guideline(s) . | ACCP 2012, ACC/AHA 2020 . | ACCP 2012, ACC 2017 . | ACCP 2012, ASH 2018 . | ||||
| Thrombotic risk . | Criteria . | Recommendation . | Criteria* . | Recommendation . | Criteria . | Recommendation . | |
| High | • All mitral valve • Caged-ball and tilting disc • Stroke or TIA in past 6 months | Suggest bridging/reasonable to bridge | CHADS2 >4 | CHA2DS2-VASc >7 | Suggest bridging | • Within 3 months • Severe thrombophilia | CHEST 2012: Suggest bridging ASH 2018: Not addressed |
| Moderate | Bileaflet aortic valve + risk factors • Atrial fibrillation • Prior stroke or TIA • Hypertension • Diabetes • Congestive heart failure • Age >75 years | Individualized decision based on patient and procedural nuances | CHADS2 3-4 | CHA2DS2-VASc 5 or 6 | Individualized decision based on patient and procedural nuances | • Past 3-12 months • Recurrent VTE • Active cancer • Nonsevere thrombophilia | CHEST 2012: Individualized decision based on patient and procedural nuances ASH 2018: Do not bridge |
| Low | Bileaflet aortic valve without risk factors | Do not bridge | CHADS2 ≤2 | CHA2DS2-VASc <4 | Do not bridge | More than 12 months ago | CHEST 2012: Do not bridge ASH 2018: Do not bridge |
ACCP 2012 based on CHADS2; 2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation based on CHA2DS2-VASc.
ACC, American College of Cardiology; ACCP, American College of Chest Physicians; AHA, American Heart Association.