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Physician Preferences for Perioperative Anticoagulation in Patients With a Mechanical Heart Valve Who Are Undergoing Elective Noncardiac Surgery^*

^* From the Department of Medicine (Drs. Douketis, Crowther, Mr. Cherian, and Dr. Kearon), St. Joseph’s Hospital (Drs. Douketis and Crowther), Hamilton, Ontario, Canada; and the Hamilton Health Sciences Corporation (Dr. Kearon), McMaster University, Hamilton, Ontario, Canada.

Correspondence to: James D. Douketis, MD, St. Joseph’s Hospital, Room F-513, 50 Charlton Ave East, Hamilton, ON, Canada, L8N 4A6; e-mail: jdouket{at}fhs.mcmaster.ca

Study objective: To determine physicians’ anticoagulation preferences in patients with a mechanical heart valve who are undergoing elective surgery, and to determine the effect of different risks of thromboembolism (TE) and postoperative bleeding on anticoagulation preferences.

Design: Mail survey of physicians who prescribe anticoagulant therapy.

Methods and results: Physicians were asked to provide anticoagulation preferences in four clinical scenarios of patients with a mechanical heart valve who are undergoing elective surgery. Physicians were asked to select from three preoperative anticoagulation options (two aggressive, one less aggressive) and four postoperative anticoagulation options (two aggressive, two less aggressive). IV heparin was the most frequently selected anticoagulation option. Depending on the scenario, it was preferred by 39 to 79% of respondents for preoperative anticoagulation therapy, and by 44 to 84% of respondents for postoperative anticoagulant therapy. The risk of TE had a strong influence on anticoagulation preferences: more respondents preferred aggressive anticoagulant management in high-risk compared with low-risk TE scenarios (p < 0.001). Anticoagulation preferences were not influenced by the risk of bleeding: the proportion of respondents who preferred aggressive anticoagulant management did not differ in high-risk and low-risk bleeding scenarios (p > 0.05). Of respondents who preferred IV heparin for postoperative anticoagulation therapy, the risk of bleeding influenced the timing of heparin initiation: fewer respondents preferred early heparin initiation (within 12 h after surgery) in high-risk compared with low-risk bleeding scenarios (p < 0.01).

Conclusions: (1) Preoperative and postoperative IV heparin were the most frequently selected anticoagulation options. (2) The risk of TE, but not the risk of bleeding, influenced the aggressiveness of anticoagulant management. (3) If IV heparin was selected, the risk of bleeding influenced the timing of heparin initiation.

Key Words: anticoagulation • embolism • mechanical heart valve • surgery • thrombosis

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