Guidelines on the antithrombotic therapy in patients with prosthetic valves by the American College of Cardiology/American Heart Association (ACC/AHA) [1, 2] and by the European Society of Cardiology (ESC)  agree on most issues. Both accepting the need of anticoagulation intensity stratification according to valve position and other risk factors, and in general, concur, that many patients can be managed with lower intensity anticoagulation than previously recommended. Both concede that individual patient risk assessment is crucial, but, the ACC/AHA utilises this only to adjust anticoagulation and/or antiplatelet therapy, whereas the ESC underlines the importance of risk reduction or treatment as an integral part of overall antithrombotic strategy. The guidelines, however, disagree on many fundamental issues: 1) the antithrombotic management of bioprostheses in the first 3 months post-operatively, 2) The risk categorisation of mechanical valves, 3) The management of embolism in the presence of adequate anticoagulation, 4) the adjunct role of antiplatelets, and 5) the bridging of anticoagulation interruption for non-cardiac surgery. In this editorial the utility of heparins (unfractionated heparin (UFH) and low molecular weight heparin (LMWH)) is revisited in some special circumstances.
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