Heparin Use in Infective Endocarditis

Primary Recommendation

The American College of Chest Physicians recommends against routine anticoagulant therapy in patients with infective endocarditis, unless there is a separate indication for anticoagulation unrelated to the endocarditis itself, with a Grade 1C recommendation indicating clear evidence of harm outweighing benefit 1

Discontinue warfarin and replace with heparin in patients with prosthetic valves on warfarin who develop endocarditis, primarily driven by the need for rapid reversibility if urgent surgery becomes necessary 2, 3, 4
The American Heart Association suggests that heparin can be easily reversed if emergency valve surgery is required, whereas warfarin effects take days to dissipate 2, 3

Immediately discontinue all anticoagulation if neurological symptoms develop during endocarditis, until intracranial hemorrhage is excluded by MRI or CT scanning, as recommended by the European Society of Cardiology 2, 3, 4
For patients with intracranial hemorrhage, interruption of all anticoagulation is mandatory, with a Class I recommendation from the European Society of Cardiology 5, 6
For ischemic stroke without hemorrhage, replacement of oral anticoagulants with unfractionated or low molecular weight heparin for 1-2 weeks should be considered under close monitoring, with a Class IIa recommendation from the European Society of Cardiology 5, 7, 6

Anticoagulation should be discontinued for at least 2 weeks of antibiotic therapy to prevent hemorrhagic conversion in patients with mechanical valve endocarditis complicated by embolic stroke, with a Class IIa recommendation and Level of Evidence C from the American Heart Association 8
Heparin should be used with extreme caution in patients with infective endocarditis, as recommended by the American Heart Association 8

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 cases of S. aureus endocarditis under close monitoring, with a Class IIa recommendation from the European Society of Cardiology 5, 7, 6

For patients with non-bacterial thrombotic endocarditis and systemic or pulmonary emboli, treatment with full-dose IV unfractionated heparin or subcutaneous low molecular weight heparin is suggested over no anticoagulation, with a Grade 2C recommendation from the American College of Chest Physicians 1

Do not confuse infective endocarditis with non-bacterial thrombotic endocarditis, as they have opposite anticoagulation recommendations, as noted by the European Society of Cardiology and the American College of Chest Physicians 1, 5, 9
Do not continue anticoagulation if neurological symptoms develop, always exclude intracranial hemorrhage first, as recommended by the European Society of Cardiology and the American Heart Association 2, 3, 4
Do not assume heparin will prevent embolic events, the evidence for anticoagulant therapy in endocarditis is based on a low level of evidence, and routine use is not supported, as noted by the American Heart Association 8
Do not forget to discontinue antiplatelet therapy, aspirin should also be discontinued in patients with endocarditis unless a separate indication exists, as recommended by the American College of Chest Physicians and the American Heart Association 1, 2