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
- 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