Anticoagulation after bioprosthetic aortic valve replacement: Are the guidelines being followed?

Sept. 27, 2023

An important quality measure after cardiac surgery is guideline-directed medication adherence. Mayo Clinic evaluated compliance with the American College of Cardiology and American Heart Association guidelines for warfarin use after surgical aortic valve replacement (sAVR) using bioprostheses and examined potential variations in anticoagulation practice over time. The findings were published in the March 2023 issue of The Annals of Thoracic Surgery.

Using the OptumLabs Data Warehouse, Mayo Clinicinvestigated adult patients who had bioprosthetic sAVR with or without coronary artery bypass between 2007 and 2019. Early postoperative warfarin use was defined as 30 or more days of continuous prescription coverage after sAVR.

Among 10,730 adult patients who had sAVR, 3,071 (28.6%) received warfarin early postoperatively. Median length of warfarin prescription coverage was 4.5 months (interquartile range, 3.0 to 8.9 months). However, only 11.1% of patients (736 of 6,634) had warfarin prescription coverage of 3 to 6 months in compliance with the most recent guidelines. Yearly warfarin prescription rate did not change significantly during the 13-year period (P = 0.386). Compared with patients from the nonwarfarin group, those receiving warfarin prescriptions were older and more likely to be male and to have atrial fibrillation, congestive heart failure, chronic pulmonary disease and a congestive heart failure, hypertension, age, diabetes mellitus, prior stroke or TIA or thromboembolism, vascular disease, age, sex category (CHA2DS2-VASc) score of 2 or higher. Warfarin use was also greater in patients receiving prescriptions for other cardiac medications (P < 0.05).

Anticoagulation after sAVR as reflected by warfarin prescriptions may be underused; the rates of warfarin use have not changed in the last decade. Although additional studies are needed to confirm the benefit of early anticoagulation after sAVR, these results indicate that most clinicians do not follow guideline recommendations. The findings highlight a potentially important area for quality improvement.

For more information

Huang Y, et al. Anticoagulation after bioprosthetic aortic valve replacement: Are we following the guidelines? The Annals of Thoracic Surgery. 2023;115:619.

Refer a patient to Mayo Clinic.