What is the recommended International Normalized Ratio (INR) goal for patients undergoing Transcatheter Aortic Valve Replacement (TAVR)?

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INR Goal for TAVR Patients

For patients undergoing Transcatheter Aortic Valve Replacement (TAVR), anticoagulation with a vitamin K antagonist (VKA) to achieve an INR of 2.5 may be reasonable for at least 3 months after the procedure in patients at low risk of bleeding. 1

Evidence-Based Recommendations

Anticoagulation After TAVR

  • The 2017 AHA/ACC guidelines provide a Class IIb recommendation (Level of Evidence: B-NR) for anticoagulation with a VKA to achieve an INR of 2.5 for at least 3 months after TAVR in patients at low risk of bleeding 1
  • This recommendation is based on evidence showing that valve thrombosis may develop in patients after TAVR when assessed by multidetector computerized tomography
  • Studies have demonstrated that prosthetic valve thrombosis occurs in patients who received antiplatelet therapy alone but not in those treated with VKA 1

Rationale for Anticoagulation

  • The incidence of valve thrombosis after TAVR varies from 7% to 40%, depending on whether patients are from clinical trials or registries and whether they received anticoagulation 1
  • Up to 18% of patients with thrombus formation developed clinically overt obstructive valve thrombosis 1
  • A post-TAVR antithrombotic regimen without warfarin appears to predispose patients to valve thrombosis 1

Antiplatelet Therapy

  • In addition to potential anticoagulation, clopidogrel 75 mg daily may be reasonable for the first 6 months after TAVR, along with lifelong aspirin 75-100 mg daily (Class IIb, Level of Evidence: C) 1
  • This recommendation is based on protocols used in prospective randomized controlled trials of balloon-expandable TAVR for treatment of aortic stenosis 1

Important Considerations

Duration of Therapy

  • Anticoagulation is typically recommended for at least 3 months after TAVR 1
  • This timeframe is intended to decrease the risk of thromboembolism until the prosthetic valve is fully endothelialized

Risk Assessment

  • The potential benefit of anticoagulation therapy must be weighed against the risk of bleeding
  • Anticoagulation is specifically recommended for patients at low risk of bleeding 1
  • The decision should prioritize prevention of valve thrombosis and thromboembolic events, which can significantly impact morbidity and mortality

Direct Oral Anticoagulants (DOACs)

  • The utility of DOACs in TAVR patients is unknown at this time 1
  • DOACs are contraindicated for mechanical valve prostheses (Class III: Harm, Level of Evidence: B) 1

Clinical Algorithm for TAVR Anticoagulation

  1. Assess bleeding risk after TAVR
  2. For patients at low bleeding risk:
    • Consider VKA with target INR of 2.5 for at least 3 months
    • Add clopidogrel 75 mg daily for 6 months
    • Maintain lifelong aspirin 75-100 mg daily
  3. For patients at high bleeding risk:
    • Consider antiplatelet therapy alone (clopidogrel + aspirin)
    • Monitor closely for valve thrombosis with imaging
  4. For all patients:
    • Regular follow-up to assess for signs of valve thrombosis or bleeding
    • Consider imaging surveillance with echocardiography

By following these evidence-based recommendations, clinicians can help minimize the risk of valve thrombosis and thromboembolic events while maintaining an acceptable bleeding risk profile in patients who have undergone TAVR.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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