What interventions are recommended for a 53-year-old male with left facial droop, recent dental infection, and complex medical history including mechanical heart valves, atrial fibrillation, and non-adherence to warfarin therapy?

Management of Left Facial Droop with Mechanical Valve and Warfarin Non-Adherence

Primary Diagnosis and Immediate Action

This patient has Bell's palsy (peripheral facial nerve palsy) secondary to dental infection, not a stroke, and the most critical intervention is resuming therapeutic anticoagulation immediately given his mechanical aortic valve and chronic atrial fibrillation. 1

The CT imaging definitively ruled out acute stroke, and the clinical presentation—with forehead involvement, eyelid weakness, and temporal association with dental infection—confirms peripheral (Bell's palsy) rather than central facial weakness. 2

Critical Anticoagulation Management

Immediate Warfarin Resumption

Restart warfarin immediately at his usual maintenance dose, as his current INR of 1.4 is dangerously subtherapeutic for a patient with a mechanical aortic valve. 1

• Target INR: 2.5-3.5 for mechanical aortic valve (higher than the 2.0-3.0 used for atrial fibrillation alone) 1, 2
• His mechanical valve mandates lifelong anticoagulation with warfarin—DOACs (dabigatran, rivaroxaban, apixaban) are contraindicated with mechanical valves 1, 3

Bridging Anticoagulation Protocol

Initiate bridging therapy with low-molecular-weight heparin (LMWH) or unfractionated heparin immediately while warfarin is being re-established, given the extremely high thromboembolic risk (>10% annually) with mechanical valves. 4

• LMWH preferred: Enoxaparin 1 mg/kg subcutaneously every 12 hours 4
• Continue bridging until INR reaches therapeutic range (≥2.5) on two consecutive measurements 4
• The mechanical valve itself mandates bridging regardless of CHA₂DS₂-VASc score 4

INR Monitoring Schedule

Check INR daily until therapeutic range is achieved and stable. 1

• Once stable in therapeutic range, check INR 2-3 times weekly for 1-2 weeks 1
• Then weekly for 1 month 1
• Then monthly when consistently stable 1

Dental Infection Management

Complete the amoxicillin course for the extensive dental disease with periapical lucencies and regional gas involving left maxillary teeth. 2

• Urgent dental referral for definitive treatment of the extensive dental disease identified on CT 2
• The dental infection is the likely trigger for Bell's palsy 2

Bell's Palsy Treatment

Initiate prednisone 60-80 mg daily for 7-10 days (started within 72 hours of symptom onset for maximum benefit). 2

• Eye protection is critical: artificial tears during day, lubricating ointment at night, eye patch or tape eyelid closed during sleep 2
• The patient reports symptoms worsening over the past week, so corticosteroids should still be offered though efficacy decreases after 72 hours 2

Addressing Medication Non-Adherence

Implement a structured anticoagulation management plan with close follow-up, as the patient admits to routinely not taking medications regularly. 1

Specific Interventions:

• Anticoagulation clinic referral for specialized warfarin management and monitoring 1
• Patient education emphasizing stroke risk: With mechanical valve + atrial fibrillation + diabetes + hypertension, his annual stroke risk without anticoagulation exceeds 15-20% 1
• Pill organizers and reminder systems 5
• Consider home INR monitoring if available and patient is appropriate candidate 1
• Social work consultation to address barriers to medication adherence 5

Risk Stratification

This patient has multiple high-risk features making anticoagulation non-negotiable:

• Mechanical aortic valve (highest risk) 1, 4
• Chronic atrial fibrillation 1
• CHA₂DS₂-VASc score = 4 (HTN=1, Age 53=0, DM=1, Male=0, but mechanical valve supersedes this scoring) 1
• History of incomplete heart block requiring pacemaker 6

Common Pitfalls to Avoid

Do not mistake peripheral facial palsy for stroke when forehead is involved—central lesions spare the forehead due to bilateral cortical innervation 2

Do not use DOACs in this patient—dabigatran is Class III: Harm with mechanical valves 1, 3

Do not delay bridging anticoagulation—every day at subtherapeutic INR with a mechanical valve carries significant thrombotic risk 4, 6

Do not target INR 2.0-3.0—mechanical aortic valves require INR 2.5-3.5 1

Do not assume patient understanding—explicitly discuss the life-threatening consequences of warfarin non-adherence with mechanical valves 4, 5

Disposition and Follow-Up

Admit for bridging anticoagulation and close INR monitoring, or arrange daily outpatient INR checks with home LMWH if reliable follow-up can be ensured. 4, 7

• Given documented non-adherence, admission is strongly preferred 7, 5
• Neurology consultation for Bell's palsy management if not improving 2
• Dental surgery consultation for definitive treatment of dental disease 2
• Cardiology follow-up within 1 week of discharge 1, 6