NOAC and mechanical heart valve

45-year-old man for Right middle finger terminalisation revision


  • AVR 2015 post episode of Infective endocarditis
  • Ex-IVDU on methadone program
  • Current smoker – 20+pack years
  • Hepatitis C – treated
  • PVD
  • ETOH excess – intermittent 


  • Anticoagulated with warfarin but self-ceased in last 6-12 months
  • Multifactorial reasons – social and transport difficulties
  • Unable to travel for pathology testing as no longer holds a Driver’s license  
  • GP has referred to cardiology in hospital 3 times in last few months, appointment pending
  • Commenced on therapeutic clexane in clinic but when called patient to check on him he had also recommenced his warfarin


  • Cardiology MDT – NOAC not an option. Requires warfarin anticoagulation.
  • Current evidence – NOAC’s are inferior to warfarin for stroke and thromboembolic prevention with mechanical heart valves. NOAC’s also carry an increased bleeding risk in this population. See attached RE-ALIGN trial.
  • Echocardiogram should be done urgently to assess valve
  • Discussion centred around difficulties of trying to resolve long-term issues in perioperative clinic. Can be very time-consuming and patient often in the room when advice is being sought. Adds to time pressure
  • May often be better to refer to GP but this has its own limitations, especially during COVID times.
  • Collaborative approach after clinic appointment often works best


  • Continue warfarin and cease Clexane
  • Recheck INR
  • Echocardiogram organised