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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?

  1. Hold all anticoagulants for several days and re-evaluate neurological status.
  2. Start intravenous UFH to get APTT 2.0 x normal and increase warfarin to achieve INR 3.0.
  3. Start weight based subcutaneous LMWH and withhold the warfarin.
  4. 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.