INR Goals for Mechanical Heart Valves

Target INR Based on Valve Position and Risk Factors

The American College of Cardiology recommends an INR goal of 2.5 (range 2.0-3.0) for bileaflet or current-generation single tilting disc mechanical aortic valves without additional risk factors 1, 4
The American College of Cardiology recommends a higher INR goal of 3.0 (range 2.5-3.5) for aortic mechanical valves with additional risk factors, including previous thromboembolism 5, hypercoagulable state 6, older-generation prosthesis 1, and severe left ventricular dysfunction 1, 3, 7
The American College of Cardiology recommends an INR goal of 3.0 (range 2.5-3.5) for all mechanical mitral valve replacements 1, 2, 4

The American Heart Association suggests that the addition of low-dose aspirin (75-100 mg daily) to VKA therapy may be considered for patients with mechanical valves, especially those with additional risk factors for thromboembolism 5, 6
The American College of Cardiology recommends that the addition of aspirin should be balanced against increased bleeding risk 5, 4

For patients with mechanical aortic valve who experience a stroke or systemic embolic event while in therapeutic range, it is reasonable to increase INR goal from 2.5 (range 2.0-3.0) to 3.0 (range 2.5-3.5) 6
For patients with mechanical mitral valve who experience a stroke or systemic embolic event while in therapeutic range, it is reasonable to increase INR goal from 3.0 (range 2.5-3.5) to 4.0 (range 3.5-4.0) 6
The American Heart Association recommends adding daily low-dose aspirin (75-100 mg) after assessing bleeding risk for patients with mechanical valves who experience a stroke or systemic embolic event while in therapeutic range 8, 6

Fluctuations in INR are associated with increased complications in patients with prosthetic heart valves 4
Patient compliance may be challenging with higher INR goals, with studies showing patients with target INR between 2.0-3.5 were within range 74.5% of the time, while those with target INR of 3.0-4.5 were within range only 44.5% of the time 2, 3
Direct thrombin inhibitors (dabigatran) are contraindicated in patients with mechanical valve prostheses 8
Anti-Xa direct oral anticoagulants have not been assessed and are not recommended for mechanical valve prostheses 8
For older-generation mechanical valves, a higher INR target of 2.5-3.5 is recommended even in the aortic position 9