Therapeutic target values in oral anticoagulation — Justification of Dutch policy and a warning against the so-called moderate-intensity regimens

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Abstract
Careful scrutiny of relevant thrombosis prevention studies in the light of recent knowledge on the responsiveness to the anticoagulant defect of the various prothrombin time assays used in these studies casts serious doubts on the adequacy of the so-called moderateintensity warfarin regimens, currently recommended by British and North American experts, in the majority of clinical situations. As long as there is strict laboratory monitoring, more intensive anticoagulation provides satisfactory prevention of thromboembolic events. The Federation of Dutch Thrombosis Centers recommends a target of 3.0 International Normalized Ratio (INR) for the primary and secondary prevention of venous thrombosis and thromboembolism, 3.5 INR in case of recurrence under the former regimen and for patients at risk for a cardiogenic embolism from any source (including tissue heart valve replacement) and those with atherothrombotic disease, and 4.0 INR for patients with a mechanical heart valve prosthesis. The risk of hemorrhage at such levels of anticoagulation remains acceptable.