European Heart Journal Advance Access originally published online on September 6, 2007
European Heart Journal 2007 28(20):2553-2554; doi:10.1093/eurheartj/ehm354
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Discrepancy in guidelines for the prevention of thrombo-embolism in patients with prosthetic heart valves: reply
Hôpital Bichat
Service de Cardiologie
46 rue Henri Huchard
Paris 75018
France
E-mail address: alec.vahanian{at}bch.aphp.fr
We read with interest the comments from Dr Stefanidis et al., which point out some discrepancies between the recommendations in the recent guidelines on the management of patients with valvular heart disease1,2 and in particular those on the management of patients with atrial fibrillation.3
Guidelines are supposed to represent the best of our current knowledge, thus, they can only be supported by the knowledge existing in the field today. Unfortunately, in valvular disease, the level of evidence is more limited than in other domains and recommendations usually rely on expert consensus.
These limitations apply to the use of antiplatelet drugs on top of anticoagulation in patients with valve prostheses. Available trials show that antiplatelet drugs can be beneficial in patients with vascular disease alone as well as in those with vascular disease and prosthetic valves. The decrease in thrombo-embolic risk observed with the addition of antiplatelet drugs seems to be more related to a decrease in complications of coronary artery disease (myocardial infarction, heart failure, and sudden death) rather than to all embolic events.4 But it has not been demonstrated that this benefit is also present in those without vascular disease. In addition, all trials show consistently that when added to anticoagulation these agents increase the risk of bleeding. Thus, the ESC Task Force on Valvular Heart Disease propose to tailor this combined therapy to specific indications and not to expand to all patients.
We recommend tailoring the degree of anticoagulation to the thrombo-embolic risk of the specific prosthesis and the patient. In a given patient with atrial fibrillation, the degree of anticoagulation is higher than those in sinus rhythm with no other risk factors.
Finally, there is no evidence to support the long-term use of antiplatelet agents in patients with bioprostheses who have no other indications.
These recommendations are also that of the ACC/AHA/ESC guidelines on atrial fibrillation,3 but are different to those in the ACC/AHA guidelines on valvular heart disease.2
However, it should be noted that fortunately the ACC/AHA and the ESC guidelines on valve disease are overall consistent in most domains and convey the same messages, the differences being in some topics where evidence is lacking.
Generally speaking, we agree that the large number of published guidelines, even more so if their recommendations are discordant, may well cause confusion for the reader and therefore limit their use in clinical practice, which is the final goal. The comments made by Dr Stefanidis should support the performance of further trials to provide better evidence and also that of consensus papers between the different Tasks Forces on a given field to underline the main messages and explain the potential discrepancies.
References
- Vahanian A, Baumgartner H, Bax J, Butchart E, Dion R, Filippatos G, Flachskampf F, Hall R, Iung B, Kasprzak J, Nataf P, Tornos P, Torracca L, Wenink A, Priori SG, Blanc JJ, Budaj A, Camm J, Dean V, Deckers J, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo J, Zamorano JL, Zamorano JL, Angelini A, Antunes M, Fernandez MA, Gohlke-Baerwolf C, Habib G, McMurray J, Otto C, Pierard L, Pomar JL, Prendergast B, Rosenhek R, Uva MS, Tamargo J. Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J (2007) 28:230–268.
[Free Full Text] - Bonow RO, Carabello BA, Kanu C, de Leon AC Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B, American College of Cardiology/American Heart Association Task Force on Practice Guidelines; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation (2006) 114:e84–231.
[Free Full Text] - Fuster V, Ryden LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S. Task Force on Practice Guidelines, American College of Cardiology/American Heart Association; Committee for Practice Guidelines, European Society of Cardiology; European Heart Rhythm Association; Heart Rhythm Society. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation-executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation). Eur Heart J (2006) 27:1979–2030.
[Free Full Text] - Turpie AG, Gent M, Laupacis A, Latour Y, Gunstensen J, Basile F, Klimek M, Hirsh J. A comparison of aspirin with placebo in patients treated with warfarin after heart valve replacement. N Engl J Med (1993) 329:524–259.
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