Warfarin Mandatory for Mechanical Valves — EECC MCQ
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Correct answer: E — Warfarin is mandatory — DOACs are absolutely contraindicated with mechanical heart valves based on the RE-ALIGN trial which showed increased thromboembolism and bleeding with dabigatran compared with warfarin
The RE-ALIGN trial (2013) compared dabigatran with warfarin in patients with mechanical heart valves and was terminated early due to excess thromboembolic events (valve thrombosis, stroke) and bleeding with dabigatran. This established an absolute contraindication for DOACs with mechanical valves — one of only two absolute contraindications (the other being moderate-severe rheumatic mitral stenosis). The 2024 ESC AF Guidelines and 2025 VHD Guidelines mandate warfarin for all mechanical valves. INR targets vary by valve position and generation: mechanical MVR: INR 2.5-3.5; modern bileaflet mechanical AVR without risk factors: INR 2.0-3.0. Self-monitoring of INR at home is recommended to improve TTR.
Reference: ESC (2024): AF Guidelines; ESC/EACTS (2025): VHD Guidelines; RE-ALIGN Trial