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160 Cardio Diabetes Medicine 2017

ed in addition.(1A) Anticoagulation with a VKA to or ischemic stroke patients.
achieve an INR of 2.5 is recommended in patients Patients with ischemic stroke or TIA with acute MI
with a mechanical aortic valve replacement (AVR) and with left ventricular mural thrombus or anterior or
no risk factors, an INR of 3.0 in patients with risk apical wall-motion abnormalities with a left ventricu-
factors (atrial fibrillation, previous thromboembolism, lar ejection fraction <40% who are intolerant to VKA
left ventricular dysfunction, or hypercoagulable con- therapy because of nonhemorrhagic adverse events,
ditions) or an older-generation mechanical AVR (such treatment with an LMWH, NOAC s for 3 months may
as ball-in-cage)or with a mechanical mitral valve re- be considered as an alternative to VKA therapy for
placement (1B).Aspirin 75-100 mg/d is recommend- prevention of recurrent stroke or TIA ( IIb , C).
ed in all patients with a bioprosthetic aortic or mitral
valve. (11a, B). Anticoagulation with a VKA is done Heart Failure and Sinus Rhythm: Anticoagulation is
for the first 3 months after bioprosthetic mitral valve not well established in patients with HF in stable
replacement or repair to achieve an INR of 2.5. (11A , rhythm or a previous thromboembolic event( IIb).
C). Anticoagulation with a VKA to achieve an INR of Heart Failure (NYHA Class II – IV) and Atrial Fibrilla-
2.5 is given for the first 3 months after bioprosthet- tion: An oral anticoagulant is recommended for all
ic AVR. (11b, B). Clopidogrel 75 mg/d may be given patients with a CHA2 DS2 -VASc score ≥1, and irre-
for the first 6 months after transcatheter aortic valve spective of whether a rate- or rhythm-management
replacement in addition to lifelong aspirin 75 -100 strategy is used including after successful cardiover-
mg/d. (11b,C). NOACs should not be used in patients sion ( 1A).
with mechanical valve prostheses. (111 B)
Patients with AF of ≥48 h duration, or unknown du-
INFECTIVE ENDOCARDITIS : ration , an oral anticoagulant is recommended at a
therapeutic dose for ≥3 weeks prior to electrical or
Neurological complications occurs in 15–30% of pa- pharmacological cardioversion ( 1C). When urgent
tients and occur either before or at the event but electrical or pharmacological cardioversion is needed
recurrent or new events can also occur . Emergen- and not on prior anticoagulants intravenous heparin
cy cardiac surgery is done after a transient ischemic or LMWH is recommended(1C).
attack or silent embolism after recovery from coma
and excluding intracerebralhaemorrhage. (1B) For Based on a CHA2DS2-VASc score, NOACs are pre-
ruptured or very large enlarging aneurysms neuro- ferred as they are associated with a lower risk of
surgery or endovascular therapy is recommended. stroke, intracranial haemorrhage and mortality, which
Intracranial infectious aneurysms should be ruled by outweigh the increased risk of gastrointestinal haem-
imaging. (1B) orrhage( 11a , B). Combination of an oral anticoagulant
and an antiplatelet agent is not recommended in pa-
PATENT FORAMEN OVALE tients with chronic (>12 months after an acute event)
Exclusion of other causes of stroke before attrib- coronary or other arterial disease, because of a high
uting PFO as the cause. Recurrent strokes despite risk of serious bleeding. Single therapy with an oral
adequate medical therapy with no other mechanism anticoagulant is preferred after 12 months.
identified, clinicians may offer the AMPLATZER Heart Failure and LV Thrombus: OAC for 6 months .
PFO Occluder if it is available (Level C). Antiplatelet OAC can be stopped after 3 months if the repeat im-
medications are given instead of anticoagulation to aging is normal ansd there is recovery of wall motion.
patients with cryptogenic stroke and PFO in the ab-
sence of an indication for anticoagulation (Level C). HYPERTROPHIC CARDIOMYOPATHY: Anticoagula-
Recurrent strokes which occurs while a patient is on tion is indicated in patients with HCM with AF inde-
antiplatelet therapy, for cryptogenic stroke and PFO pendent of the CHA2 DS2 -VAScscore(1 B).No data
anticoagulation is preferred. (Level C). on NOACS.
AORTIC ARCH ATHEROSCLEROSIS : It is associated
ACUTE MYOCARDIAL INFARCTION AND with 3-4 fold increase in the risk of cerebral embolism
LEFT VENTRICULAR THROMBUS : if the plaque is more than 4mm. Antiplatelet ther-
Patients with acute anterior STEMI with no left ven- apy is recommended for patients with an ischemic
stroke or TIA and evidence of aortic arch atheroma
tricular mural thrombus formation but with anterior (1A). Statin therapy is also recommended (1 B). Effec-
apical akinesis or dyskinesis identified by echocardi- tiveness of anticoagulation with warfarin, compared
ography or other imaging modality (IIb; C), 3 months with antiplatelet therapy, is unknown ( IIb; C). Surgical
of VKA therapy is given targeting an INR of 2.5 in TIA

GCDC 2017