In patients with mechanical prosthetic heart valves, effective antithrombotic therapy requires continu- ous effective warfarin anticoagulation with an INR in the target range.33 ACC/AHA guidance on the selection of the most appropriate antithrombotic regimen in patients with mechanical heart valves has been published in separate guidelines.33 Anticoagulation with warfarin to achieve an INR of 2.5 is typically recommended for patients with a mechanical bileaflet or current-generation single- tilting-disk aortic valve replacement and no risk factors for thromboembolism.458,469,472,473 However, patients with an aortic mechanical prosthesis who have a history of ischemic stroke or TIA are at higher risk of thromboembolic complications, and it is recommended to maintain the INR at a higher target of 3.0 (range, 2.5 3.5) or to add aspirin 75 6. Neurological complications are the most frequent and severe extracardiac complications of IE, with an estimated incidence of up to 20% to 40% and a significant impact on mortality.460 462 Ischemic cerebrovascular events represent the most com- mon neurological complication of IE. Risk factors for ischemic stroke or TIA include vegetation size and mobility, infection with Staphylococcus aureus, and involvement of the mitral valve.460 Timely and appropriate institution of antibiotic therapy is the first-line therapy for patients with IE and embolic stroke or TIA. ACC/AHA guid- ance on the management of patients with IE has been published in separate guidelines.33,463 In patients with IE and recurrent embolic stroke or TIA despite antibiotic therapy, an early consid- eration for surgery (during the index hospitaliza- tion and before completion of a full therapeutic course of antibiotics) is reasonable if there is no evidence of intracranial hemorrhage or extensive 7. 