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A 48-year-old woman with a St. Jude mechanical MVR placed 10 years ago comes in with low-grade fevers and acute onset of a right hemiparesis. Her exam, aside from a temperature of 38.1 C, was normal with a crisp closing click of the MVR and no systolic or diastolic murmur. Echocardiogram showed normal LV size and function, normally seated MVR with a mean gradient of 4 mmHg at an HR of 66. TEE showed a mobile linear echodensity attached to the atrial surface of the MVR 8 mm in length. A CT of the head was consistent with an acute left cerebral infarction. Her INR was 2.4 on admission.
What is the appropriate management of her anticoagulation?
- Hold all anticoagulants for several days and re-evaluate neurological status.
- Start intravenous UFH to get APTT 2.0 x normal and increase warfarin to achieve INR 3.0.
- Start weight based subcutaneous LMWH and withhold the warfarin.
- Increase warfarin to achieve INR >3.0, holding off on bridging heparin.
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1. Source: "Comparative Analysis of Pre/Post Assessments of Live/Didactic Course Attendees when compared to Mico-Learning/Online Course Users., "Knowledge to Practice, 2017.