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Mechanical Valve Warfarin Only — RACP Adult Medicine MCQ

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EasyCardiologyMechanical Valve Warfarin OnlyRACP Adult Medicine

A 65-year-old man with AF and a mechanical mitral valve prosthesis (CHA₂DS₂-VASc 3) is on warfarin with time in therapeutic range of 70%. His INR control is good. He asks about switching to a DOAC for convenience. What is the most appropriate advice?

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Correct answer: D — Warfarin (target INR 2.0-3.0)

Mechanical heart valves are an ABSOLUTE CONTRAINDICATION to DOACs. The RE-ALIGN trial (dabigatran vs warfarin in mechanical valves) was stopped early due to excess thromboembolism and bleeding with dabigatran. Warfarin is the ONLY anticoagulant approved for mechanical valves. Target INR depends on valve type and position: mitral mechanical valves typically require INR 2.5-3.5. Patient should continue warfarin.

Reference: CSANZ – 2024 – Valvular Disease; ESC 2021; RE-ALIGN Trial