2-weeks post op with high INR

[Tell-Tale Heart]

My aortic valve was replaced on Friday, 5/25. I chose a mechanical valve to reduce the possibility of repeat surgeries.
Four days post op (Tues, May 29), my INR was 1.6
The next day I was told I would be getting Fragmin shots, which would continue a few days after release. Got my first shot on Wed, May 30 (in hospital) and told I am getting 4 Mgs. Warfarin plus an aspirin (325) daily.
Released on Thurs, 5/31 - INR is 1.8 (target 2.0-2.5)
Visiting nurse visit Friday - still on Fragmin, Warfarin & aspirin. INR is 1.7 (portable meter?)
Told to increase warfarin to 5 mg. starting Sun, June 3.
Visiting nurse visit Mon, June 4. No draw - the nurse said too soon since Friday
Tuesday, June 5 last Fragmin shot. Headache and eye pain since Monday evening.
Visiting nurse Wed. June 6. INR 6.1 !!!!!
Told to discontinue all warfarin & aspirin and "stay down" until next test on Friday. Can't do anything that could lead to brain hemmorage or other bleeding. Which I'm told could be anything.
So I've been sitting here for almost 2 days trying to keep it together. My BP is up (oh, really??) I miss my walks! This is crazy! I feel like OHS was the easy part. So scared and sad. Why can't they test more often? Is it really so hard to balance INR?

 

[Protimenow]

It's not really that difficult to manage INR - but post-op management is a bit more of a hassle.

An INR of 6.1 should be verified with a blood draw (unless your INR was from a blood draw). You didn't indicate how that test was run.

6.1 is scary and can be a bit troubling. However, sitting in bed for two days probably isn't the best thing for you, either. (Years ago, I had an INR of 7.2, if I recall. The doctor told me to not do anything stupid for a few days.) Sure, your risks of hemorrhage are increased with a 6.1 - if that's a correct value - but people with such high INRs DO get along just avoiding activities that can cause bruising or hard impacts.

Are you completely off Warfarin? If so, you may wind up in what we often call the 'INR Roller Coaster.' I'm hoping that you've reduced your dose, but not stopped it entirely. This way, when your body's reaction to the too high dosing drops off, and it's out of your system, you're not back at 1.7 again and trying to figure out how to get in range.

Until you are in range, I don't have a problem with testing every 3 or 4 days - or weekly. With the cost of strips around $5-8 each, frequent testing to determine where your INR currently is wouldn't be extremely expensive, and may help you determine the proper dosage for your body.

Remember, though, that as your body continues to heal, its response to warfarin may not be consistent.

If it was me, I'd probably not avoid some walks even with an INR of 6.1 -- I'd just be careful until the INR dropped within range.

(You ARE considering getting a meter, aren't you?)

 

[Mom2izzy]

When my INR went up too much, they told me to have some greens (salad with spinach and romaine for me). My understanding was that the vitamin K counteracts the effects of the Warfarin. I thought they told me that was better than just waiting for it to come down because it works quickly. I was also told that every change in warfarin dose will take 3 days to register in your INR result, so you have to be careful not to continue adjusting before the most recent dose has time to take effect. I got lucky and only had to be on warfarin for a month, so I'm definitely don't have the expertise of others on the forum. Hope you get this under control soon...hang in there!

 

[newmitral]

Hello Tell-Tale Heart,

No, warfarin management is not that hard, but it did take a few weeks for the doctors to balance my own dose after my valve replacement. I was also under target, having to take Lovenox shots while they slowly increased the warfarin dose until I got within range.

I'm certainly not an expert but a few things about your post seem odd to me.

1. The increase from 4mg to 5mg seems unusual as most dosing protocols would call for a 10% increase in dose, not a 25% increase. So I'm surprised that they didn't go to a 4.5mg dose (a 4mg pill plus half of a 1mg pill) before jumping to 5mg.

2. Most of the time, the aspirin prescribed to be taken with the warfarin is the "baby" 81mg aspirin, not the full 325mg aspirin.

3. Your target range of 2.0 to 2.5 seems tighter than most aortic valve replacement patients. 2.0 to 3.0 is more typical.

4. You did not indicate whether the nurse that got the 6.1 reading repeated the test to be sure it was not a mistake. Your mention of the headaches and eye pain is the only reason to think it might be real, since a jump from 1.7 to 6.1 in only 4 days, with the increased dose only for 3 of those days, seems very unusual.

Mom2izzy's recommendation to chow down on a large spinach salad is good advice as it will help to bring down an elevated INR faster. Also, avoid cranberry juice as (some literature still indicates) it may elevate INR.
My own reaction to stopping the warfarin is that my INR drops very quickly without dietary help, but everyone reacts differently.

Testing tomorrow (Friday) is probably fine, although many ACT managers would recommend testing one day after stopping the warfarin with INR above 6.

It gets easier with more personal history of how your body reacts to the warfarin, but educating yourself on the standard dosing algorithms/protocols so you know if the advice you are getting is "standard" is probably a good idea.
There are several dosing protocol papers out there, but I personally like the one at:

http://www.hopkinsmedicine.org/hema...ing_algorithm_Kim_YK_and_Kaatz_S_JTH_2010.pdf


While you are waiting for the next test on Friday (tomorrow), which I hope will show you are back down to a safe level, I recommend reading through the posts on dosing, so you can be more confident in the advice your ACT manager is giving, and you can avoid the roller-coaster that Protimenow referred to. Your doctor may have good reason to recommend non-standard dosing changes for your individual care, but at least if you are familiar with the standard recommendations, you can ask him to give you an explanation of what those reasons are. "Trust but verify" is a phrase that comes to mind.

[update] Another possibility occurred to me. You might want to also familiarize yourself with the way to identify warfarin pills by their color and stamped dosage markings. While highly unlikely, it is possible that your pharmacist gave you pills of a different dosage strength than you reported. You can learn to identify and verify the various pill dosages via the info/pictures at:

http://pillbox.nlm.nih.gov/pillimage/search_results.php?submit=Search&splid=&getingredient=Warfarin

or any number of other sites you can find via google.

 

[TheGymGuy]

All the advice given here is very very sound.

I wanted to chime in and just say that cranberry juice has no effect on INR, see this http://www.valvereplacement.org/forums/showthread.php?35040-INR-cranberry-juice-study

 

[neil]

sorry youre having a rough time, hopefully it will get sorted soon, chin up

 

[newmitral]

Hi GymGuy,

I don't want to hijack this thread for a discussion on cranberry/warfarin interaction -- that should best be discussed in its own thread. However, the medical jury is apparently still out on that issue.
The 2009 paper in the thread you referenced studied only nine (9) individuals that showed no effect on INR. Even within that paper, the authors admit:

Another reason for this discrepancy is that the interaction
may be unpredictable and rare, and nine patients,
perhaps, is an insufficient sample size to demonstrate this
possibility.

At least two more recent articles on the NIH website:
http://www.ncbi.nlm.nih.gov/pubmed/21364039
and
http://www.ncbi.nlm.nih.gov/pubmed/22231999

indicate cases where there appears to be a documented interaction.
The literature I received from Johns Hopkins after my surgery in 2011 indicated there may be an interaction, and cranberry is still listed in the potential interaction list on the handout with my most recent warfarin prescription refill.

So, I feel justified in advising the original poster of the (arguable) potential interaction with cranberry, unless he has already determined that he is among that portion of the population not affected by it.
If I were in his shoes, with an INR already elevated (assuming it isn't just a flawed test result), I would play it safe and avoid the stuff at least until my INR was safely within range.

Personally, I like cranberry juice and after reading the paper you referenced I plan to check out whether it effects my INR or not. I will re-introduce it to my diet and see if it raises my (now stable) INR.
But, for the situation the original poster is experiencing, I would still recommend he avoid it for now and experiment later.

 

[bocco]

I'd bet my money on the 6.1 number being a mistake. Going from 1.8 to 6.1 in 6 days just seems like a big jump unless you are a very small person. It took me that long to get from 1.4 to 2.1 after leaving the hospital.

 

[Protimenow]

I agree with Bocco on this. It's been well documented that the meters are less accurate with higher INRs than they are with lower ones. A 6.1 reported by a meter may be, perhaps, a 5.0 on a lab test. Sure, this is still way too high, but it's not as bad as a 6.1.

It's also usual protocol to verify any INR above 4.5 (from what I've seen) with a blood draw. Hell, I'd probably verify a 6.1 from a blood draw by retesting the blood or a new blood draw.

If the 6.1 WAS from blood collected by the nurse, there are many things that could make the results inaccurate. The tube with blood could have been improperly handled. It may have been stored in a hot car for quite a while when the nurse visited other patients, the lab could have used an old reagent -- who knows? To me, it only makes sense to repeat the test and verify this rather high value. (In retrospect, I had a 7.1 a decade or so ago, and I don't remember the doctor requesting another blood draw right away).

Even with a 6.1, I don't think you need to wrap yourself in a cocoon for a few days until the INR drops closer to being in range.

It will be interesting to see what your INR is today.

 

[Tell-Tale Heart]

Thank you all for your responses and advise. I'm back on track again. The stickies have also been a very useful tool.
For clarification, here is more info about the questions you had.
I don't know what triggered the increase from 4 mg. to 5 mg, but I suspect it was prescribed based on the INR decrease from 1.8 to 1.7 when discharged from the hospital.
The aspirin vs. baby aspirin thing is because I've taken regular aspirin daily for over 20 years, so they just continued with it.
I'll confirm the tight INR target range again - I'm sure 2.0 was the bottom, but I was pretty scrambled when some of this was laid out.
The nurse indicated an INR result of 6.1 (finger stick) should be verified with a vein draw, but didn't follow up or retest. Now I know what to request (demand) if I have a problem again.

Went to the lab yesterday and my INR is back to 2.52. Yeah! Also got a call from the surgeon and will take 4 mg. Warfarin tonight & tomorrow, then reduce to 2 mg. So I'll finally sleep tonight. Thanks again to all who responded!