Recommendation 31. For patients with a mechanical valve replacement, we suggest an initial regimen of ASA 81 mg daily plus clopidogrel 75 mg daily plus a VKA (triple therapy). ASA may be discontinued as early as the day after PCI or it can be continued up to 6 months of treatment, depending on the risk of recurrent thrombotic events vs major bleeding (Weak Recommendation; Very Low-Quality Evidence).
Recommendation 32. For patients with a mechanical valve replacement, we recommend against the use of a NOAC regardless of whether it is in combination with antiplatelet therapy or used alone (Strong Recommendation; Moderate-Quality Evidence).
Values and preferences. After PCI, the uninterrupted use of a VKA (warfarin) is critical to minimize the risk of valve thrombosis in patients with a mechanical valve. A NOAC should not be used in this setting. The duration of triple therapy will vary depending on an individual patient's risk of thrombotic vs bleeding events. In patients with low risk of thrombotic events and high risk of bleeding, the duration of triple therapy can be short, with omission of ASA as early as the day after PCI. In patients with high risk of thrombotic events and low bleeding risk, the duration of triple therapy can be longer, for up to 6 months of treatment. Patients at intermediate risk of thrombotic and bleeding events the duration of triple therapy will be somewhere in between.
Practical tip. In patients with a mechanical heart valve, warfarin is specifically indicated. Other OACs are not recommended.
Recommendation 33. For patients with a surgical bioprosthetic valve replacement, (implanted < 6 months), we suggest DAPT with ASA 81 mg daily and clopidogrel 75 mg daily for at least 6 months (and up to 12 months) (Weak Recommendation; Very Low-Quality Evidence).
Recommendation 34. For patients with a TAVR (implanted < 6 months), we suggest DAPT with ASA 81 mg daily and clopidogrel 75 mg daily for 3-6 months (Weak Recommendation; Very Low-Quality Evidence).