International normalized ratio patient self-management for mechanical valves: is it safe enough?

PURPOSE OF REVIEW: People with mechanical heart valve replacement depend on lifelong anticoagulation. Since a few years, patients can control this themselves with the assistance of a portable anticoagulation monitor. If the patient performs the complete self-testing and self-adjustment by himself, the method is called self-management. Recently completed studies concerning international normalized ratio (INR) self-management in mechanical heart valve patients are reviewed in this article.

RECENT FINDINGS: Large randomized prospective studies have demonstrated that the INR self-management concept results in well-trained patients with a high percentage of their measured INR values lying within the predetermined therapeutic range, thus resulting in a low rate of complications such as bleeding and thromboembolism. The reduced anticoagulation level resulted in fewer grade III bleeding complications (which means there is a need for surgery or endoscopy, in-hospital treatment or permanent damage) without increasing thromboembolic event rates.

SUMMARY: The concept of INR self-management is a promising tool to achieve low hemorrhagic complications without increasing the risk of thromboembolic complications. Data of the Early Self-Controlled Anticoagulation Trial (ESCAT II) study demonstrate that low-dose INR self-management does not increase the risk of thromboembolic events compared with conventional-dose INR self-management.