A Middle-Aged Man With AFib and Mechanical Heart Valve

A 54-year-old male with a history of a bi-leaflet mechanical mitral valve implantation secondary to rheumatic heart disease is admitted for an episode of epistaxis requiring nasal packing in the setting of an INR of 4.6. On review of the medical records, you notice that since the mechanical mitral valve implantation five years ago, he has been admitted twice for suspected TIAs and once for a small ischemic stroke with INRs <2.0. Since then, he has been managed with warfarin and aspirin. On review of laboratory data, it appears that his time in therapeutic range is limited with supratherapeutic INR values observed quite frequently.

During the history, he reports being concerned about continuing on warfarin, stating "I cannot keep my blood thinner levels steady – no matter what I do! And between my job and small children, I cannot keep coming back to get my blood checked and ending up in the hospital." His medical history is otherwise unremarkable and laboratory studies are noteworthy for normal liver and renal function, with a reduced hemoglobin of 9.9 gm/dL (previously 13.5 gm/dL). A 12-lead ECG reveals atrial fibrillation with a regular rate.

His wife asks "Can my husband try one of the new blood thinners?"

What is the most appropriate anticoagulation strategy for this patient upon discharge?

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