International Normalized Ratio (INR) Targets: Valvular Disease

The international normalized ratio (INR) recommendations below are per guidelines from the American College of Chest Physicians (2008). ^[1]

Rheumatic mitral valve disease

Recommendations for rheumatic mitral valve disease include the following:

• INR target (range)

  • Atrial fibrillation (AF), prior embolism, and/or left atrial thrombus: 2.5 (2.0-3.0)

  • AF plus systemic embolism or left atrial thrombus: 3.0 (2.5-3.5)

  • Normal sinus rhythm plus left atrial diameter >55 mm: 2.5 (2.0-3.0)

  • Preprocedure percutaneous mitral balloon valvotomy (PMBW) with left atrial thrombus: 3.0 (2.5-3.5)

• Duration of therapy: Long-term

Mitral valve prolapse

Recommendations for mitral valve prolapse include the following:

• INR target (range)

  • AF, systemic embolism, or recurrent transient ischemic attacks (TIAs): 2.5 (2.0-3.0)

• Duration of therapy: Long-term

Mitral annular calcification

Recommendations for mitral annular calcification include the following:

• INR target (range)

  • Recurrent systemic embolism, ischemic stroke, or TIA, without AF: 2.5 (2.0-3.0)

  • AF: 2.5 (2.0-3.0)

• Duration of therapy: long-term

Acute deep venous thrombosis (DVT) of the arm

Recommendations for acute deep venous thrombosis (DVT) of the arm include the following:

• INR target (range): 2.5 (2.0-3.0)

• duration of therapy: ≥3 months

Calcific aortic valve disease

Recommendations for calcific aortic valve disease include the following:

• INR target (range)

  • Ischemic stroke: 2.5 (2.0-3.0)

• Duration of therapy: Long-term

Patent foramen ovale

Recommendations for patent foramen ovale include the following:

• INR target (range)

  • Cryptogenic ischemic stroke plus risk factors: 2.5 (2.0-3.0)

• Duration of therapy: Long-term

Mechanical heart valve

Recommendations for mechanical heart valve include the following:

• INR target (range)

  • Bileaflet mechanical valve in aortic position, sinus rhythm, no left atrial enlargement: 2.5 (2.0-3.0)

  • Tilting-disk or bileaflet mechanical valve in mitral position: 3.0 (2.5-3.5)

  • Caged-ball or caged-disk: 3.0 (2.5-3.5)

  • Risk factors: 3.0 (2.5-3.5)

  • Systemic embolism despite therapeutic INR: Increase from 2.5 to 3.0 (2.5-3.5) or 3.0 to 3.5 (3.0-4.0)

  • Aortic position with prosthetic valve thrombus: 3.5 (3.0-4.0)

  • Mitral position with prosthetic valve thrombus: 4.0 (3.5-4.5)

• Duration of therapy: Long-term

Bioprosthetic heart valve

Recommendations for bioprosthetic heart valve include the following:

• INR target (range)

  • Mitral position: 2.5 (2.0-3.0)

  • History of systemic embolism: 2.5 (2.0-3.0)

  • Left atrial thrombus: 2.5 (2.0-3.0)

  • Risk factors: 2.5 (2.0-3.0)

• Duration of therapy

  • Mitral position: 3 months

  • History of systemic embolism: ≥3 months

  • Left atrial thrombus: Until documented resolution

  • Risk factors: Long-term

• Risk factors: AF, anterior-apical ST-segment elevation myocardial infarction, left atrial enlargement, hypercoagulable state, low ejection fraction